Coding Consult

Emphysema and PFTs

Having trouble choosing the correct code for pulmonary function tests (PFTs) for emphysema?

A patient with emphysema (492–492.8) typically presents with a variety of symptoms, including shortness of breath (786.05), wheezing (786.07), breathlessness (786.09), renal insufficiency (593.9), and congestive heart failure (428.0). There are a number of in-office tests to properly diagnose the disease, including PFTs (94010-94799) and chest X-rays (71010-71555). First report codes for the presenting symptoms; once you diagnose emphysema, report the appropriate diagnosis code.

Here are three tips on PFT code selection to enhance your reimbursement.

Know 94010 and 94060 bundling rules

When you suspect a patient has emphysema, you perform either spirometry (94010, spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) or a bronchospasm evaluation (94060, bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]).

The bronchospasm evaluation involves spirometry taken before and after you dilate the airways by administering a bronchodilator (94640, pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]).

Remember, you can't report both spirometry and bronchospasm tests on the same day—the National Correct Coding Initiative bundles 94010 into 94060. NCCI also bundles several other tests with 94060, including 94375 (respiratory flow volume loop), 94200 (maximum breathing capacity, maximal voluntary ventilation), 94770 (carbon dioxide, expired gas determination by infrared analyzer), 94640, and 94664 (demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

If you do the tests in the office, you may bill for the bronchodilator medication, such as albuterol (J7618).

"But when you do the tests in a hospital or other outpatient facility, you can't bill for the supplies because the facility delivers them," says Toni Revel, a coding expert and nurse practitioner in Warrington, PA.

If you don't own the PFT equipment, append modifier –26 (professional component) to 94010 or 94060 for your interpretation of the test results. You can only report these codes without modifier –26 if you both own the equipment and interpret the results.

Unbundle stress tests from spirometry

You could encounter coding complications if you decide to perform a pulmonary stress test. For example, you administer a stress test, which you code as 94620 (pulmonary stress testing; simple [e.g., prolonged exercise test for bronchospasm with pre- and post-spirometry]).

"Your carrier may consider spirometry bundled with this service," Revel says. In that case, append modifier –59 (distinct procedural service) to differentiate the stress test from the initial spirometry.

Suppose you see a 65-year-old woman who has dyspnea (786.0x) and a cough (786.2) after she walks several city blocks. Both her stress test and spirometry come back normal. As she walks on the treadmill, she begins to have difficulty breathing, and you get a repeat spirometry to evaluate the patient for exercise-induced bronchospasm.

"Even though the original spirometry tested normal, the patient showed bronchospasm symptoms, which may establish medical necessity to unbundle the service," says Judy Richardson, a senior consultant at the coding firm Hill & Associates in Wilmington, NC. Attach a copy of the patient's records to the claim and prepare yourself for an appeal, she adds.

Depending on the severity of the emphysema, you might order pulse oximetry, 94760 (noninvasive ear or pulse oximetry for oxygen saturation; single determination) and blood gas testing (82803-82810). You may be tempted to bill for these procedures, but remember that Medicare considers pulse oximetry incidental and includes the service in the E&M visit.

"Submit 94760 to Medicare only if you didn't perform any other service on the patient that day," Richardson says. For example, a physician checks a pulse's oximetry on a patient who presents with severe chest pain (786.50) and administers no other tests or services that day.

Report 99215 for treatment consults

Because you can increase your level of medical decision-making when testing a patient for emphysema, you may be able to code for a higher level of E&M service.

"But remember, if you're treating an established patient, you must meet two of the three components: history, exam, and decision-making," Revel says. "And if the patient is new, you must meet all three."

For instance, your established patient is a heavy smoker. He complains of chest pains (786.50) and wheezing (786.07). Because you must determine the severity of the emphysema, develop a treatment plan, run various tests, and interpret results, you could report 99214 (office or other outpatient visit). In addition to fulfilling two of the three E&M components, if you consult with a pulmonologist (say the patient's symptoms have worsened and may require a referral), you could report 99215.

"Make sure your documentation supports a 99215," Richardson says. Chart each step you take. For example, describe how you'll treat the patient's chest pains and wheezing, and which tests you performed to determine the severity of the disease.

Other commonly billed PFT codes include:

• 94070 (prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine, or other chemical agent, with subsequent spirometrics).

• 94014 (patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration, and physician review and interpretation).

• 94015 (recording [includes hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic recalibration]).

• 94016 (physician review and interpretation only).

Codes 94014, 94015, and 94016 will be paid once in a 30-day period. Medicare reimburses initial hospital and office consults, initial hospital visits, and new-patient office visits, in addition to PFTs when performed on the same day. Medicare also reimburses follow-up or subsequent E&M services in addition to PFTs when the E&M service is for a significant, separately identifiable condition.

This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Road South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.

Coding Consult: Emphysema and PFTs.

Medical Economics

Dec. 5, 2003;80:19.