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Careful Coding Critical to Correct Reimbursement for Pulmonary Function Testing

Accurate coding and reporting of pulmonary function testing (PFT) can be challenging at times. A careful review of CPT and ICD-9-CM codes will ensure that the testing facility receives proper reimbursement for its services.

CPT codes for pulmonary testing are found in the medicine section of CPT in the range of 94010 to 94799. This range of codes includes the actual procedure and the interpretation of the test results. When evaluation and management (E/M) services are provided in addition to pulmonary testing, report them separately and append modifier "-25" to the E/M code.

If there's no exact code available, then an unlisted code is required, not a code that's "close to" what was actually done. Use of an unlisted procedure code requires submission of a report that documents what was done and the reason why another, more commonly performed procedure wasn't appropriate. It isn't true that "unlisted codes are never paid."

Other types of laboratory testing, such as blood gas analysis, with codes in the clinical laboratory section of CPT are reported separately. The term "laboratory" in the pulmonary guidelines refers to the pulmonary codes performed in pulmonary departments or labs and not to the codes in the lab series (80048-89399). Codes from both sections should be reported when appropriate.

A CPT code reported without a modifier indicates that the global service was performed. If only the technical component of the service is done, then the "-TC" modifier is reported. If only the professional component of the service is performed, as when independent physicians interpret PFTs performed in hospital outpatient respiratory therapy departments, modifier "-26" is reported by the physician. PFTs performed in a laboratory owned by the interpreting physician are reported without modification.

A number of tests in the pulmonary section are components of each other and wouldn't be reported separately to some payers due to the National Correct Coding Initiative (NCCI) edits. These edits, which are updated quarterly, contain code pairs that may not be reported together on a claim.

The Centers for Medicare and Medicaid Services announced recently that the NCCI edits are available on the Internet at Previously, these edits were only available by paid subscription.

Coding edits fall into two categories: mutually exclusive codes and comprehensive/component codes. Mutually exclusive code pairs are those that a person would never expect to be reported together, either because of the wording of the CPT code description or clinical practice. If two mutually exclusive codes are reported together, the reimbursement will be for the lesser procedure.

An example of a mutually exclusive code pair within the PFTs is 94070 (prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometries) and 94620 (pulmonary stress testing; simple - such as prolonged exercise test for bronchospasm with pre- and post-spirometry).

An example of a comprehensive/component code pair within the pulmonary section is 94620 and 94200 (maximum breathing capacity, maximal voluntary ventilation). The second code is a component of the first and wouldn't be reported separately. Reporting both would constitute "unbundling," or the separating of a procedure into its component parts and billing them separately.

Each of the code set examples also contains a modifier status indicator as follows:

0: Modifier not allowed. The presence of any modifier won't affect the prohibition against using this code set together.

1: Modifier allowed. Use of the appropriate modifier (usually "-59") will mediate this edit, and the codes may be reported together. This should be done only if the procedures actually were performed as separate tests. The modifier shouldn't be applied routinely to assure reimbursement where none is due. Be sure that there's documentation in the health record to support the reporting of both codes and the medical necessity for performing them separately.

9: Not applicable. This status is mostly assigned to code sets that have been deleted but still appear in the NCCI.

Careful Coding Critical to Correct Reimbursement for Pulmonary Function Testing

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