Confusion over Pulmonary Diagnostic Services Coding
Sometime you might receive a claim denial while billing for evaluation and management (E/M) services and pulmonary diagnostic procedures provided to the same patient on the same date. Physicians has lot of confusion on how to billing accurately for Pulmonary Diagnostic Services. Pulmonary diagnostic procedures, such as spirometry, are commonly done in family medicine in conjunction with another E/M service. When a physician performs a pulmonary function study and obtains a limited history and exam, separately coding for an E/M service is inappropriate. However, if the physician performs a significant, separately identifiable E/M service unrelated to the technical performance of the pulmonary function test, the physician may report an E/M service with modifier 25 appended to the E/M code. In this article, we discussed basics for pulmonary diagnostic services coding and pulmonary function testing.
Basics for Pulmonary Diagnostic Services Coding
Procedure code 94150 (Vital Capacity, total) represents a service that has a B-status indicator on the Medicare Fee Schedule for Physician’s services. Therefore, this service is bundled into payment for other services. It is expected that procedure code 94070 will only be performed to make an initial diagnosis of asthma. It is expected that procedure code 94060 be utilized during the initial diagnostic evaluation of a patient.
Repeat spirometry performed to evaluate the patient’s response to newly established treatments, monitor the course of asthma/COPD, or evaluate patient’s continuing with symptomatology after initiation of treatment should be utilized with procedure code 94010. It is not expected that a pulse oximetry (procedure code 94760 or 94761) for oxygen saturation would routinely be performed with spirometry.
The residual volume (RV) cannot be measured by spirometry and is determined by subtracting the expiratory reserve volume (ERV) from the functional residual capacity (FRC). The FRC cannot be measured by simple spirometry either. Therefore, procedure code 94726 or 94727 should be used when the RV and FRC need to be determined.
Documentation Requirements (for Pulmonary Diagnostic Services)
- All documentation must be maintained in the patient’s medical record and made available to the payer upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- If the provider of the service is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the studies. The physician must state the clinical indication/medical necessity for the study in his order for the test.
- Test results and interpretation must be correlated with the clinical presentation of the patient and documented in the medical records. The specific procedures performed must be used for decision making and not duplicative of information obtained. Therefore, documentation should support that the test results and interpretation were used for the treatment of a specific medical problem by the physician who ordered the services.
Pulmonary Function Testing
Spirometry is a critical component for diagnosing and managing pulmonary disease. The test allows the physician to evaluate the degree of airway obstruction, the effectiveness of the current therapy, and gives the opportunity to customize medications to ensure adequate daily control. Test results are available immediately following the procedure for evaluation and interpretation. Scheduling, interpretation of the PFT, nebulizer set-ups, compressor, liquid or inhaled albuterol for inhalation, and normal saline is supplied by the physician’s office. Most insurance carriers cover this service.
Procedure Codes for Pulmonary Function Testing
- CPT codes relative to Medicare’s standards of reasonable and necessary care are: 94070, 94200, 94640, 94726, 94727 and 94729.
- Spirometry – CPT codes for Spirometry include 94010, 94011, 94012, 94060, 94070, 94150, 94200, 94375, 94726 and 94727. Routine and/or repetitive billing for unnecessary batteries of tests is not clinically reasonable.
- Lung Volume: CPT codes for lung volume determination are 94013, 94726, 94727 and 94728.
- Diffusion Capacity: CPT codes for diffusion capacity include 94729.
- Pulmonary stress testing: CPT codes for pulmonary stress testing include 96417, 96418, 94619 and 96421.
- CPT 94664 is intended for device ‘demonstration and/or evaluation’ and will be usually paid for once per beneficiary for the same provider or group. (Occasional extenuating circumstances, new equipment, etc., may merit two sessions or other repeat training or evaluation. Simple follow-up observation during an E/M exam for pulmonary disease is not a stand-alone procedure, unless the E/M session is not billed).
Documentation Requirements (for Pulmonary Function Testing)
- Supportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request.
- Payers can request additional documentation from third parties (e.g. ordering physician) when needed to evaluate the medical necessity of the service and may consider care prior to or subsequent to the service in question.
- Each claim must be submitted with ICD-10-CM codes that reflect the actual condition of the patient. The mere listing of an ICD-10-CM code alone does not justify the test if the overall context and condition of the patient do not support necessity of the test.
- All providers of pulmonary function tests should have on file a referral (an order, a prescription) with clinical diagnoses and requested tests. Indications in the primary medical record must be available for review.
- All equipment and studies should meet minimum standards as outlined by the American Thoracic Society.
- Spirometry studies, in particular, require 3 attempts to be clinically acceptable.
- All studies require an interpretation with a written report. Computerized reports must have a physician’s signature attesting to review and accuracy.
- Documentation must be available to payer upon request and must be legible. The medical record must document the test results and usage in treatment.
- American Thoracic Society and the American Lung Association and the American College of Chest Physicians have published guidelines for typical usage of pulmonary function tests which represent typical community norms.
- Follow up testing which is weekly or monthly is appropriate only when clinically required, such as in periods of acute exacerbation of interstitial lung disease.
- PFTs are diagnostic, not therapeutic. PFTs are not used to demonstrate breathing exercises.
- Demonstration/observation of a nebulizer (94664) is usually used once or at rare intervals as a stand-alone procedure code.
Legion Health Care Solutions is a leading medical billing company providing complete billing and coding services. For detailed understanding of basics for Pulmonary Diagnostic Services coding, we referred CMS local coverage article ‘Billing and Coding: Pulmonary Diagnostic Services’. For detailed assistance in medical billing and coding for your practice, contact us at 727-475-1834 or email us at email@example.com