Procedure Code Description 2016 National Averages1 Facility Non-Facility
94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation $36.52 $36.52
94010 TC Technical Component $27.93 $27.93
94010 26 Professional Component $8.59 $8.59
94060 Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration $61.58 $61.58
94060 TC Technical Component $48.34 $48.34
94060 26 Professional Component $13.25 $13.25
Procedure Codes for Spirometry
The following common procedure terminology codes (CPT Codes) describe the various spirometric procedures and the national average reimbursement amount. They include, but are not limited to:
|
CPT Code
|
Component
Code |
Description
|
National Fee
|
|
94010
|
00520,
94200, 94375, 95070, 95071 |
Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without MVV.
|
$34.12
|
|
94014
|
00520, 94010,
94015, 94016, 94200, 94375 |
Patient-initiated spirometric recording per 30 day period of time; includes reinforced education, transmission of spirometric tracings, data capture, analysis of transmitted data, periodic recalibration and physician review and interpretation.
|
$48.74
|
|
94015
|
00520, 94010,
94200, 94375 |
Patient-initiated spirometric recording per 30 day period of time; recording (includes hook up, reinforced education, data transmission, data capture, trend analysis and periodic recalibration).
|
$24.57
|
|
94016
|
00520, 94015,
94375 |
Patient-initiated spirometric recording per 30 day period of time; physician review and interpretation only.
|
$24.17
|
|
94060
|
00520, 36000,
36410, 94010, 94200, 94375, 94640, 94664, 94770, 95071 |
Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration.
(Report bronchodilator separately with 99070 or appropriate supply code) (For prolonged exercise test for bronchospasm with pre-and post-spirometry, use 94620). |
$58.58
|
|
94200
|
|
Maximum breathing capacity, maximal voluntary ventilation (MVV).
|
$22.96
|
|
94375
|
00520
|
Respiratory Flow Volume Loop.
|
$36.81
|
|
94620
|
00520, 93015, 93016, 93017, 93018, 93041, 93042, 94010, 94060, 94200, 94250, 94680, 94681, 94690, 94760, 94761, 94770
|
Pulmonary stress testing; simple (eg, 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry)
|
$89.12
|
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Pulmonary diagnostic tests will be considered medically necessary for the indications outlined below. It is expected the provider of services will follow a thoughtful, purposeful sequence in his/her selection of tests appropriate to the patient’s presenting complaint, medical history, physical examination, etc.
Indications
Pulmonary diagnostic services will be considered reasonable and medically necessary when
· Ordered by the patient’s treating physician for a specific medical problem; and
· When performed only by providers of pulmonary services or other providers who have specialized training and expertise in performing pulmonary diagnostic services.
The CMS Manual System, Pub. 100-08, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf outlines that “reasonable and necessary” services are “ordered and/or furnished by qualified personnel.”
A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare. B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.
Pulmonary function studies 94010, 94060, 94070, and 94375 must be: (1) performed by a qualified physician, or (2) performed under the general supervision of a qualified physician by a technologist (i.e. medical assistant, nurse) who has been trained to perform these tests by a qualified physician.
Pulmonary function studies 94621, 94726, 94727, 94728, 94729 and 94750 must be: (1) performed by a qualified physician, or (2) performed under the general supervision of a qualified physician by a technologist who has demonstrated minimum entry level competency by being credentialed by a recognized national credentialing body such as the National Board for Respiratory Care (NBRC). In addition to receiving credentialing by a recognized national credentialing body, qualified technologists must have a state license.
Examples of certification for pulmonary diagnostic testing by non-physician personnel include:
· Certified Pulmonary Function Technician (CPFT)
· Registered Pulmonary Function Technician (RPFT)
· Certified Respiratory Therapist (CRT)
· Registered Respiratory Therapist (RRT)
· Perinatal/Pediatric Care Specialist
In addition to credentialing requirements, a state license is required if mandated by the state/territory of the practicing clinician. In the absence of a state/territory licensing or credentialing process, documentation should be maintained by the supervising physician which demonstrates appropriate training of staff performing the services. This documentation should be available upon request.
Limitations
The use of pulmonary diagnostic function testing as part of the routine clinical exam is not a covered benefit. In instances where studies are recommended as part of a preoperative evaluation in a patient with no active pulmonary symptoms, the record must document the rationale for the study (i.e. long history of smoking, asbestos exposure, exposure to toxic drugs, etc). Studies performed in the absence of such documentation will be considered not reasonable and medically necessary.
Patient initiated spirometry (94014, 94015 and 94016) are non covered and will not be reimbursed.
Pulmonary Function Tests
PFTs measure two components of the respiratory system: the mechanical ability of the respiratory system to move air in and out of the lungs; and the effectiveness of the respiratory system in exchanging oxygen and carbon dioxide with the atmosphere. A PFT includes three possible components:
1. Spirometry (94010, 94060, 94070)
2. Lung Volume Determination (94250, 94726, 94727 and 94728)
Lung Volume tests cannot be measured directly using Spirometry because these volumes and capacities include air that cannot be expelled from the lungs. Lung Volume is generally determined in one of four ways:
Closed circuit helium equilibration
Open circuit nitrogen washout
Whole body plethysmography
Radiologic techniques
3. Diffusion Capacity Tests (94729)
The PFT will be considered medically necessary for the following conditions:
· Preoperative evaluation of the lungs and pulmonary reserve when:
– thoracic surgery will result in loss of functional pulmonary tissue (i.e., lobectomy) or
– patients are undergoing major thoracic and/or abdominal surgery and the physician has some reason to believe the patient may have a pre-existing pulmonary limitation (e.g., long history of smoking); or
– the patient’s pulmonary function is already severely compromised by other diseases such as chronic obstructive pulmonary disease (COPD).
· Initial diagnostic workup for the purpose of differentiating between obstructive and restrictive forms of chronic pulmonary disease. Obstructive defects (e.g., emphysema, bronchitis, asthma) occur when ventilation is disturbed by an increase in airway resistance. Expiration is primarily affected. Restrictive defects (e.g., pulmonary fibrosis, tumors, chest wall trauma) occur when ventilation is disturbed by a limitation in chest expansion. Inspiration is primarily affected.
· To assess the indications for and effect of therapy in diseases such as sarcoidosis, diffuse lupus erythematosus, and diffuse interstitial fibrosis syndrome.
· Evaluate patient’s response to a newly established bronchodilator anti-inflammatory therapy.
· To monitor the course of asthma and the patient’s response to therapy (i.e., especially to confirm home peak expiratory flow measurements).
· Evaluate patients who continue to exhibit increasing shortness of breath (SOB) after initiation of bronchodilator anti-inflammatory therapy.
· Initial evaluation for a patient that presents with new onset (within 1 month) of one or more of the following symptoms: shortness of breath, cough, dyspnea, wheezing, orthopnea, or chest pain.
· Initial diagnostic workup for a patient whose physical exam revealed one of the following: overinflation, expiratory slowing, cyanosis, chest deformity, wheezing, or unexplained crackles.
· Initial diagnostic workup for a patient with chronic cough. It is not expected that a patient would have a repeat spirometry without new symptomatology.
· Re-evaluation of a patient with or without underlying lung disease who presents with increasing SOB (from previous evaluation) or worsening cough and related qualifying factors such as abnormal breath sounds or decreasing endurance to perform Activities of Daily Living (ADL’s).
· To establish baseline values for patients being treated with pulmonary toxic regimens (e.g., Amiodarone).
· To monitor patients being treated with pulmonary toxic regimens when any new respiratory symptoms (e.g., exertional dyspnea, non-productive cough, pleuritic chest pain) may suggest the possibility of pulmonary toxicity.
· To evaluate cystic fibrosis patients with pulmonary manifestations.
It is expected that procedure code 94070 will only be performed to make an initial diagnosis of asthma.
Also, it is expected that procedure code 94060 be utilized during the initial diagnostic evaluation of a patient. Once it has been determined that a patient is sensitive to bronchodilators, repeat bronchospasm evaluation is usually not medically necessary, unless one of the following circumstances exist:
(1) a patient is exhibiting an acute exacerbation and a bronchospasm evaluation is being performed to determine if the patient will respond to bronchodilators;
(2) the initial bronchospasm evaluation was negative for bronchodilator sensivity and the patient presents with new symptoms which suggest the patient has a disease process which may respond to bronchodilators; or
(3) the initial bronchospasm evaluation was not diagnostic due to lack of patient effort. Repeat spirometries performed to evaluate 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.
In addition, it is not expected that a pulse oximetry (procedure code 94760 or 94761) for oxygen saturation would routinely be performed with spirometry. Pulse oximetry is considered medically necessary when the patient has a condition resulting in hypoxemia and there is a need to assess the status of a chronic respiratory condition, supplemental oxygen and/or a therapeutic regimen (e.g., acute symptoms).
Usually during an initial evaluation, there is no reason to obtain a spirometry after the administration of bronchodilators in patients who have normal spirometry, normal flow volume loop and normal airway resistance unless there is reason to believe (e.g., symptoms, exam) that a patient has underlying lung disease.
The residual volume (RV) cannot be measured by spirometry because this includes air that cannot be expelled from the lungs, and, therefore, 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 will be performed when the RV and FRC need to be determined.
The Maximum Voluntary Ventilation (MVV; procedure code 94200) is a determination of the liters of air that a person can breathe per minute by a maximum voluntary effort. This test measures several physiologic phenomena occurring at the same time. The results and success of this test are effort dependent, therefore, routine performance of this test is not recommended, except in cases such as: pre-operative evaluation, neuromuscular weakness, upper airway obstruction, or suspicion of Chest Bellows disease.
The Respiratory Flow Volume Loop (procedure code 94375) is used to evaluate the dynamics of both large and medium size airways. This test is more useful than the conventional spirogram. The procedure is the same for spirometry except for the addition of a maximal forced inspiration at the end of the force expiratory measures.
Pulmonary Stress Testing (94620, 94621)
The pulmonary stress testing procedures range from simple to complex. The simple procedure (Stage 1) consists of BP, ECG, and ventilation measurements at timed increments during exercise. The complex procedure includes Stage 2 and Stage 3. Stage 2 involves all of Stage 1 measurements in addition to the mixed venous CO2 tension (production) by means of rebreathing technique and O2 uptake. Stage 3 requires the following: (a) blood gas sampling and analysis, (b) an indwelling catheter is inserted into the brachial or radial artery, and (c) in addition to Stage 2 tests, measurements for cardiac output, alveolar ventilation, ratio of dead space to tidal volume, alveolar-arterial O2 tension difference, venous admixture ratio and lactate levels are determined.
Exercise testing is done to evaluate functional capacity and to assess the severity and type of impairment of existing as well as undiagnosed conditions. The Pulmonary Stress Test will be considered medically necessary for the following conditions:
· To determine whether the patient’s exercise intolerance is related to pulmonary disease, cardiac disease, or due to lack of conditioning or poor effort.
· Initial diagnostic workup when symptoms (generally dyspnea) are out of proportion to findings on static function (spirometry, lung volume, diffusion capacity).
· Detection of interstitial lung disease (fibrosis) or exercise-induced broncho-spasm which are only manifested by exercise.
· Evaluate patient’s response to a newly established pulmonary treatment regimen.
The majority of clinical problems can be assessed during the simple procedures included in Stage 1, and should be completed before more complex tests are performed. Abnormal results indicate that more precise information is required through more complex Stage 2 protocols. If Stage 3 protocols are implemented, arterial blood analysis is necessary. In 75% of patients, Stage 1 is sufficient. Oxygen titration can be done during graded exercise to determine the oxygen needs for improving exercise tolerance and increased functional capacity.
Absolute contraindications to exercise testing include:
· Acute febrile illness
· Pulmonary edema
· Systolic BP > 250mm Hg
· Diastolic BP > 120mm Hg
· Acute asthma attack
· Unstable angina
· Acute Myocarditis
Lung Compliance (94750)
Lung compliance measures the elastic recoil or stiffness of the lungs. It is more invasive than other PFTs, because the patient is required to swallow an esophageal balloon.
Compliance studies are performed only when all other PFTs give equivocal results, or the results require confirmation by additional data.
Spirometry Code
The spirogram requires a patient taking a maximal inhalation and then exhaling into the measurement device as hard and fast as possible. The data are plotted as both a volume-time curve and a flow-volume curve.
There are several coding options. The 94010 code describes “spirometry” and is grouped in APC 0367. The flow-volume procedure code 94375 could also be used, but it is in the same Medicare APC 0367 and thus pays the same technical fee (professional fees may be different in some regions). An argument could be made that the flow-volume curve gives information that the traditional volume-time curve does not. However, Medicare still considers the 2 procedures bundled, and one code edits out the other. The passive vital capacity procedure code 94150 should not be used for spirometry, because Medicare has assigned a $0 payment for that code. More problematic is the maximum voluntary ventilation.
This is a separate procedure, but it is often performed along with the spirogram. Although it is clearly a separate test that provides separate information, Medicare and many other payers often bundle the maximum voluntary ventilation procedure code 94200 (APC 0367) with the codes for spirometry. Nevertheless, we generally bill for it separately in the hope that some payers will recognize it as a legitimately separate procedure. If 2 spirograms are performed before and after bronchodilator, a separate procedure code exists for this (94060), which is grouped under Medicare APC 0368. This code will also edit out if billed with either spirometry or flow-volume loop; in fact, if these codes are billed together, Medicare will pay only the lower code rate.
Billing and Coding Tips:
Spirometry:
It measures the amount of air breathe in and out over a specified amount of time. If Flow Volume Loop (FVL) is displayed without bronchodilator administration, use CPT
94375. CPT 94010 is included in this procedure. If FLV is performed pre and post bronchodilator administration, use CPT 94060. CPT 94010 and 94375 are bundled with
CPT 94060.
Anthem Central Region bundles 94010 as incidental with 94060. Based on the text in the 2003 CPT manual code 94060 includes the spirometry test 94010. Based on the Correct Coding Edits for Comprehensive Codes 90000-99999; code 94010 is listed as a component code to code 94060. Therefore, if 94010 is submitted with 94060–only 94060 reimburses.
Anthem Central Region bundles 94375 as incidental with 94060. Based on Palmetto’s LMRP, Pulmonary Function Testing, Medical Policy; “CPT code 94375: Respiratory loop is not separately reimbursed when performed the same day as spirometry.” Based on the Correct Coding Edits for Comprehensive Codes 90000-99999; code 94375 is listed as a component code to code 94060. Therefore, if 94375 is submitted with 94060–only 94060 reimburses
The definitions of the supervision guidelines are as follows:
• General supervision. The physician does not need to be on site when the services are performed. The staff may perform the services without the physician present. There must be a physician order for the diagnostic procedure. An example of this situation is simple spirometry (94010).
• Direct supervision. The physician must be in the office suite when the diagnostic service is performed but does not need to be face-toface with the patient. The physician must be immediately available to provide assistance and direction for the pulmonary service.
An example is spirometry, before and after bronchodilation (94060).
• Personal supervision. The physician must be with the patient while the diagnostic pulmonary function study is being performed. An example is the methacholine challenge (94070 and 95070).
Covered ICD-10-CM Description
ICD-10-CM Code/ Range
Abnormalities of breathing R06.00-R06.9
Acute bronchiolitis J21.0-J21.9
Acute bronchitis J20.0-J20.9
Asthma J45.20- J45.998
Bacterial pneumonia, not elsewhere classified J15.0-J15.9
Bacterial pneumonia, not elsewhere classified J15.0-J15.9
Congenital pneumonia due to S. pneumoniae P23.6
Cough R05
Emphysema J43.0-J43.9
Encounter for preprocedural respiratory
examination Z01.811
Exposure to environ mental tobacco smoke* Z77.22
Hemoptysis (cough with hemorrhage) R04.2
Lobar pneumonia, unspecified organism J18.1
Nicotine dependence* F17.200- F17.299
Occupational exposure to environmental
tobacco smoke* Z57.31
Other and unspecified asthma J45.901- J45.998
Other chronic obstructive pulmonary disease J44.0-J44.9
Other diseases of upper respiratory tract J39.0-J39.9
Other respiratory disorders J98.01-J98.9
Other somatoform disorders, includesfunctional
cough, hysterical cough, or
psychogenic cough F45.8
Personal history of nicotine dependence* Z87.891
Pneumonia due to streptococcus J15.3-J15.4
Pneumonia due to Streptococcus pneumoniae J13
Respiratory conditions due to inhalation of
chemicals, gases, fumes and vapors J68.0-J68.9
Simple and mucopurelent mucopurulent
chronic bronchitis J41.0-J41.8
Simple chronic bronchitis (smoker’s cough) J41.0
Smoking (tobacco) complicating pregnancy, O99.330-
childbirth, and the puerperium O99.335
Tobacco use (NOS)* Z72.0
Toxic effect of tobacco and nicotine T65.211- T65.294
Unspecified chronic bronchitis J42
Vasomotor and allergic rhinitis J30.0-J30.9
ICD-9 Codes for Spirometry
The following ICD-9 Codes support the medical necessity for the use of a spirometer. They include, but are not limited to:
|
466 – 466.19
|
Acute bronchitis andbronchiolitis
|
|
490
|
Bronchitis, not specified as acute or chronic
|
|
491 – 491.9
|
Chronic Bronchitis
|
|
492 – 492.8
|
Emphysema
|
|
493 – 493.91
|
Asthma
|
|
494
|
Bronchiectasis
|
|
496
|
Chronic airway obstruction, not elsewhere classified
|
|
508 – 508.9
|
Respiratory condition due to other and unspecified external agents
|
|
518.9
|
Other diseases of respiratory system, not elsewhere classified
|
|
519.1
|
Bronchospasm
|
|
780.51
|
Insomnia with sleep apnea
|
|
786.2
|
Cough
|
|
780.53
|
Hyperinsomnia with sleep apnea
|
|
793.1
|
Abnormal chest x-ray
|
|
786
|
Abnormal chest sounds
|
|
277
|
Cystic Fibrosis
|
|
790.7
|
Chronic fatigue
|
|
787
|
Heartburn
|
|
E942.9
|
Other unspecified agents primarily affecting the
cardiovascular system |
|
305.1
|
History of tobacco abuse
|
|
V13.8
|
History of thyroid disorder
|
94200 is always denied with 59 modifier when billed as part of a PFT. Any suggestions
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