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Pulmonology Coding Alert

Reader Question:

LMRPs Show Medical Necessity for PFT

Published on Sat Feb 01, 2003

Question: How can I show medical necessity for a pulmonary function test (PFT)? Which codes correspond with the test to get it reimbursed? Can it be done for screening purposes?

New York Subscriber

Answer: Your report will meet medical necessity when two criteria are met: The diagnosis code is identified by the insurer as being medically necessary, and you provide adequate documentation. To find codes that substantiate medical necessity, you will need to contact the insurer or read its local medical review policies (LMRP). For example, New York State Medicare LMRPlists several diagnosis codes that show medical necessity. For example, it lists the following diagnoses that can be used to support medical necessity for CPT codes 94010, 94060, 94200, 94240, 94375 and 94720:

  • 162.0-162.9 Malignant neoplasm of trachea, bronchus, and lung

  • 466.0 Acute bronchitis

  • 492.0-492.8 Emphysema

  • 493.00-493.92 Asthma

  • 780.50-780.57 Sleep disturbances

  • 786.2 Cough

  • 790.91 Abnormal arterial blood gases.

    Medicare excludes screening testing from reimbursement. It defines screening as a PFTperformed on an asymptomatic patient, with or without high risk of lung disease and without any pre-existing cardiopulmonary condition. It also includes PFTs that are part of a routine exam and or an epidemiological survey. For example, the LMRPshows that many Vcodes are not covered:

  • V70.0 Routine general medical examination at a health care facility

  • V76.0 Special screening for malignant neoplasms of respiratory organs

  • V81.3 Special screening for chronic bronchitis and emphysema

  • V72.82 Preoperative respiratory examination

  • V70.6, V70.7 Surveys and clinical research.

    Documentation must support medical necessity, show the appropriate ICD-9 code and be submitted with each claim. All PFTs require an interpretation with a written report. Computerized reports must have a physician's signature. Providers of PFTs must have on file a referral (prescription) with clinical diagnoses and requested tests. All documentation must be available to Medicare upon request.

     

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