Understanding Basics for Pulmonary Diagnostic Services Coding

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Understanding Basics for Pulmonary Diagnostic
Services Coding
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Understanding Basics for Pulmonary Diagnostic
Services Coding
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 Physicians 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 patients response to newly established
treatments, monitor the course of asthma/COPD, or
evaluate patients continuing with symptomatology
after initiation of treatment should be utilized
with procedure code 94010.
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Understanding Basics for Pulmonary Diagnostic
Services Coding

• 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
  patients 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
  services). 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 physicians
  order for the studies. The physician must state
  the clinical indication/medical necessity for the
  study in his order for the test.

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Understanding Basics for Pulmonary Diagnostic
Services Coding

• 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 physicians office. Most insurance carriers
  cover this service.
• Procedure Codes for Pulmonary Function Testing
• CPT codes relative to Medicares 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.

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Understanding Basics for Pulmonary Diagnostic
Services Coding

• 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.

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Understanding Basics for Pulmonary Diagnostic
Services Coding

• All studies require an interpretation with a
  written report. Computerized reports must have a
  physicians 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 info_at_legionhealthcaresolutions.com

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