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Pulmonology Coding Alert

Think You've Mastered Coding for Walking Tests? Read This First

Published on Thu Sep 02, 2004

Let your patients do the walking and 94620 or 94761 do the talking

Pulmonologists often order simple or complex stress tests or use pulse oximetry to measure similar metabolic functions, but coders don't always know which stress-test code to report. 

During a stress test, the pulmonologist measures the patient's lung function according to the degree of reduced oxygen in the blood or desaturation in the lungs as dyspnea occurs after the patient walks on a treadmill or pedals on a stationary bicycle.  Alternatively, the pulmonologist may measure the distance the patient walks, dyspnea, oxyhemoglobin desaturation and heart rate during one session. The pulmonologist would use a six-minute walk test to record this information.

Case example: A patient presents with shortness of breath (786.09, Dyspnea and respiratory abnormalities; other) and a cough (786.2, Cough). Before the test, the pulmonologist records a baseline spirometry for the patient. Then the patient walks on the treadmill, and the pulmonologist records a subsequent spirometry to check for bronchospasm, says Roger Hettinger, CPC, CMC, CCS-P, coding specialist with Sioux Valley Clinic in Sioux Falls, S.D.

The Choice Is Simple ... or Complex?

For the scenario above, you peruse your CPT book and narrow the choice down to 94620 (Pulmonary stress testing; simple [e.g., prolonged exercise test for bronchospasm with pre- and postspirometry]) or 94621 (... complex [including measurements of CO2 production, O2 uptake, and electrocardiographic recordings]).

The difference: If the pulmonologist checked for exercise-induced bronchospasm and recorded pre- and postspirometry, you should report 94620 for a simple test, says Susan Rittel, RHIT, CCS-P, CPC, healthcare consultant in Fargo, N.D.  

Remember: Pulmonologists may order simple pulmonary stress tests, such as six-minute walk tests, on patients who fall into one of the following categories, Rittel says:  

  • those with the physical conditions of unexplained shortness of breath  

  • those undergoing disability evaluation to determine the severity of a disease such as asbestos  

  • those undergoing evaluation to determine if they meet Medicare's requirement for supplemental oxygen.

    Don't miss: Refer to "2 Questions You Need to Ask Before You Report Stress Tests and Bronchodilation" in this issue to understand how spirometry may make or break 94620 coding.

    94621 Tells a Larger Story

    When the pulmonologist performs a complex stress test, he integrates both cardiac and pulmonary functions with the status of the patient's physical fitness.

    To perform a complex stress test, the pulmonologist records the patient's carbon dioxide production, oxygen uptake and electrocardiographic recordings, in addition to the patient's peak cardiovascular and ventilatory responses while under physical exertion.

    Based on the results of the test, the pulmonologist looks at the patient's dyspnea index, an anaerobic threshold, as a percentage of maximum oxygen uptake and consumption as it relates to cardiac uptake.

    Hint: Complex tests usually involve more specialized equipment than a treadmill to perform a gas analysis, coding experts say. If your practice is small with limited resources, your pulmonary function lab most likely only performs simple tests.

    Oximetry Makes All the Coding Difference

    Like 94620, you should report 94761 (Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations [e.g., during exercise]) when the pulmonologist evaluates a patient during and after exercise. But, you should choose 94761 instead of 94620 only when the pulmonologist uses pulse oximetry - which does not require an exercise test - to evaluate specific metabolic functions, such as oxygen flow, that he doesn't measure in a simple stress test, coding experts say.

    Double-check: To ensure you've chosen 94761 correctly, check to see that the pulmonologist determined desaturation or oxygen flow to prevent desaturation during the test.

    Pulse oximetry allows the pulmonologist to continuously monitor oxygen saturation without measuring an arterial blood gas. Pulmonologists use pulse oximetry to evaluate the oxygen level of patients with conditions including asthma, pneumonia, bronchitis and chronic lung disease, in addition to other conditions.

    Case example: A patient complains of wheezing (786.07, Wheezing). The pulmonologist reviews the patient's history and examines her.

    The pulmonologist cannot evaluate the airways from the examination alone. Therefore, he may also use pulse oximetry and spirometry to measure pulmonary function. If he measured spirometry, you should report 94010, or 94060 if he measured spirometry before and after administering bronchodilator. If he only used multiple determinations of oximetry, you should report 94761.

    Avoid Denials for 94761 With E/M Services

    Medicare does not reimburse practices for 94761 if the pulmonologist performs another E/M service or other payable service on the same day as the stress test, Hettinger says.

    Medicare assigns a "T' status to 94760 and 94761 on the Medicare Physician Fee Schedule. The "T" status means that Medicare bundles 94760 and 94761 into the other service that the pulmonologist performs on the same day, Hettinger says.

    Bottom line: Even when you think 94761 correctly describes the procedure your pulmonologist performed, look to the documentation to double-check, because if the stress test occurred on the same day as an office visit, you shouldn't bill 94761 in addition to your E/M code, Hettinger says. But always check your local carrier's guidelines before you assume you should or should not bundle these codes.





     

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