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Pulmonary Function Test

The following specific tests for evaluating pulmonary diseases are considered for payment:PULMONARY OBSTRUCTIVE DISEASE ESTABLISHED (EOP). This category of diseases refers to conditions that reduce the lumen of the respiratory tract and produce a quantifiable reduction of the air flow

Diagnostic

ICD-10-CM

(effective 10/1/15)

Chronic bronchitis

J41.1, J44.9, J44.1, J44.0, J41.8, J42

Asthma

J45.20, J45.22, J45.21, J45.20, J45.22, J45.21, J44.0, J44.1, J45.991, J45.909

Emphysema

J43.9, J43.9

Tracheobronchitis

J95.02

Stenosis of Larynx

J38.6

Laryngeal Spasm

J38.5

Other laryngeal conditions

J38.7

Bronchiectasis

J47.9

Chronic airway obstruction

J44.9

Fumes and vapors (chronic respiratory condition)

J68.4

Bronchiolitis

J21.8

POTENTIAL PULMONARY OBSTRUCTIVE DISEASE

PULMONARY FUNCTION TESTS FOR PULMONARY OBSTRUCTIVE DISEASE

CPT 94010 – spirometry.

CPT 94060 – spirometry before and after administering the bronchodilator or exercises

CPT 94375 – «respiratory flow volume loop» its use must be associated with the following criteria:

• locate and differentiate between intra and / or extra pulmonary defects

• distinguish between «malingering» and real lung defects,

• distinguish if the lung defect is in the upper or lower tracts

Note: 94375 represents the graphic documentation of the information obtained during 94010 or 94060, in addition to providing graphic representation offers other advantages over 94010 or 94060, such as the following:

a) Differentiates between intra and extra thoracic obstruction.

b) The «flow volume loop» is the most versatile and most complete of the spirometric studies.

c) Although spirometry is the main study to establish pulmonary obstructive disease (PAD), the measurement of absolute lung volumes and the capacity of diffusion may be necessary for:

• differentiate type of lung disease

• document severity of the condition

•document non-communicating spaces

• document mild pulmonary disease

Billing guides:

Medical necessity for the services provided and frequency justification must be clearly documented in the medical record.

b. Only one of the three spirometry codes 94010, 94060 or 94375 may be billed with the appropriate ICD-9 for the initial evaluation of pulmonary obstructive disease.

c. The codes 94726, or 94727 will be covered in addition to spirometry. Only one of the two codes must be invoiced: 94726 or 94727.

• CPT 94726-94727-Plethysmography for determination of lung volumes and, when performed, airway resistance: Gas dilution washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes.

• CPT 94726-94727- Plethysmography for determination of lung volumes and, when performed, airway resistance: gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes.

• CPT 94729-Diffusing capacity (eg, carbon monoxide, membrane) (List separately in addition to code for primary procedure)

PULMONARY RESTRICTIVE DISEASE (ERP), these conditions result in a reduction in lung volume and are divided into the following categories.

A.   Conditions due to loss of lung parenchyma:

Diagnostic

ICD-10-CM

(effective 10/1/15)

Emphysema resulting from a procedure

T81.82XA

Pulmonary Collapse – Allergy

J98.11, J98.19, J98.2, J98.3, J82, J81.0, J95.3, B44.81

Neoplasm of Respiratory System

D49.1

Pulmonary Eosinophilia

J82

Pulmonary alveolar proteinosis – Idiopathic fibrosing alveolitis

J84.01, J84.03, J84.02, J84.1

Other diseases of lung

J96.00, J96.90, J80, J96.10, J96.20, J98.4

Pulmonary Manifestation Radiation

J70.1

Rheumatoid lung

M05.10

Lymphangioma, any site

D18.1

Involvement Systemic Sclerosis

M34.81

Extrinsic allergic alveolitis

J67.0, J67.1, J67.2, J67.3, J67.4,  J67.5, J67.6, J67.7, J67.8,  J67.9

Pneumoconioses

J60, J61, J62.8, J63.0, J63.1, J63.2, J63.3, J63.4, J63.5, J63.6

Unspecified alveolar and parietoalveolar pneumonopathy

J84.9

Pulmonary alveolar proteinosis

J84.01

Idiopathic pulmonary hemosiderosis

J84.03

Pulmonary alveolar microlithiasis

J84.02

Pulmonary collapse

J98.11, J98.19

B.   Extrapulmonary lesions of:

Diagnostic

ICD-10-CM

(effective 10/1/15)

Thoracic wall

·         Kyphosis

M40.00, M40.209

·         Scoliosis

M41.20

Congenital musculoskeletal deformities of spine

Q67.5, Q76.3, Q76.425, Q76.426, Q76.427, Q76.428

·         Acquired spondylolisthesis

M43.00, M43.10

·         Pectus excavatum

Q67.6

Pleural

·         Current Tuberculosis

J86.9, J94.1, J94.8, J94.9, R09.1

Neuromuscular

·         Myotonic disorders

No convierte

·         Hemiplegia

No convierte

·         Paraplegia

G82.20

·         Paralytic syndromes

G83.81, G83.84, G83.89

·         Polyneuropathy

G60.9

·         Peripheral neuropayhy

G71.0

·         Myasthenia

G70.00

·         Polymyositis

M33.20

·         Acute lateral sclerosis

C.   Pulmonary vascular diseases:

Diagnostic

ICD-10-CM

(effective 10/1/15)

·         Vasculitis

J30.1

·         Other diseases of lung not elsewhere

J98.4

D.   Combined obstructive and destructive conditions:

Diagnostic

ICD-10-CM

(effective 10/1/15)

·         Sarcoidosis

D86.9

·         Respiratory conditions

J70.1

·         Heart failure

I50.9

·         Other diseases of lung

J98.4

PULMONARY FUNCTION TESTS FOR PULMONARY RESTRICTIVE DISEASE (ERP)

CPT 94010 – Spirometry

• CPT 94726 – Plethysmography for determination of lung volumes and, when

performed airway resistance

• CPT 94727 – Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes.

• CPT 94729 – See + 94729-Diffusing capacity Eg. Monoxide carbon, membrane)

(Report + 94729 with 94010, 94060, 94070, 94375, 94726 – 94728)

Billing guides

Medical necessity and justification for the frequency must be documented in the medical record.

For evaluation and monitoring of ERP, the invoice codes are 94010, 94060, +94729.

Documentation Guides

Medical records must document the medical necessity and the frequency of the tests.

BRONCHIAL HYPERSENSITIVITY:

This category of conditions refers to those in which the patient experiences symptoms sporadically or has symptoms without physical.

Diagnostic

ICD-10-CM

(effective 10/1/15)

·         Cough

R05

·         Asthma equivalent/history of asthma with normal spirometry

R93.9

·         Other symptoms involving respiratory system and chest

R06.00, R06.09, R06.3, R06.83, R06.89

Pulmonary function tests to evaluate bronchial hypersensitivity

CPT 94070 assessment of bronchospasm with multiple spirometries after a dose of bronchodilator (aerosol only) antigen, exercise, cold, air or methacholine or other clinical agents, with spirometry as in CPT 94010.

Billing guides

CPT 94070 is covered when invoiced with any previous ICD-10 code. Medical necessity must be documented.

Documentation Guides

Medical records must document the medical necessity and the frequency of the tests.

Pulmonary function tests for preoperative evaluation:

One or more of the following tests can be used to determine the operative and postoperative risk in patients with pre-existing lung disease.

CPT

Description

94060

Bronchospasm  evaluation; 94010 before and  after bronchodilation or  exercise

94200

«Maximum Breathing Capacity, maximal voluntary ventilation».

94726

Plethysmography for determination of lung volumes and, when performed, airway resistance

94727

Gas dilution or washout for determination of lung volumes and, when performed,    distribution of ventilation and closing volumes.

94729

Ver +94729-Diffusing capacity Eg. Carbón monoxide,membrane

Billing guides

CPT 94200, 94729, 94726, 94727, are covered for:

1. Patient with a history or suspicion of lung disease who will undergo a thoracotomy or upper abdominal surgery.

2. Patients with advanced lung disease in whom the decision to carry out the surgery or refuse. This depends on the results of pulmonary function tests.

CPT-94060 is covered in:

1. The circumstances previously described (1 & 2)

2. Patients with known lung disease and that can be considered as high risk for postoperative pulmonary complications and in which high abdominal surgery is going to be carried out.

CPT 94680 is used only to evaluate patients before heart transplants.

Pulmonary Function Test where the TC component (production) is not considered for payment to the doctor. The modifier 26 (professional component) is recognized according to the guidelines below:

1. + 94729- diffusion capacity (Eg Carbon monoxide, membrane)

2. 94750-Pulmonary compliance study, any method

Coding and Billing Guides

The results of these tests are generated by a computer or by a technician, generally no additional interpretation is provided. If the physician provides a written interpretation for this test, the CPT code used must be accompanied by modifier 26 and with the appropriate diagnosis (ICD-9). These tests will only be paid when the invoice is accompanied by a report documenting the need to provide a written interpretation in addition to the results generated by the computer.

COVER FOR OTHER EXAMINATIONS OF PULMONARY FUNCTION:

CPT

Description

CPT 94150

«vital capacity, total (separate procedure)”

Billing guides

CPT 94150 It will be covered for diagnosis of obstructive pulmonary disease and is billed only (it will not be covered if invoiced with 94010, 94060, 94200 or 94375).

CPT

Description

94400

Breathing response to CO2″ (CO2 response curve).

94450

Breathing response to hypoxia» (hypoxia response curve).

94620

Pulmonary Stress Testing.  (ICD9-300.11)

Cover for blood gases and ear oximetry

CPT

Description

82803

Gases, blood, any combination of ph, pCO2, CO2, HCO2 (including calculated O2 saturation)

82805

with O2 saturation by direct measurement, except pulse oximetry

82810

Gases, blood, O2 saturation only, by direct measurement, except pulse oximetry

94760

Noninvasive ear to pulse oximetry for oxygen saturation; single determination

Billing and Coding Guides

When the diagnosis is respiratory failure with any diagnosis of obstructive and / or restrictive lung disease. Only one of the four tests described above will be accepted for payment

Usage Guidelines: Medical records must document the medical necessity and frequency of the tests. They will be covered only at ambulatory level.

Explanatory note for pulmonary function tests.

CPT

Description

94010

spirometry

94060

spirometry before and after the administration of a bronchodilator. Here the response to the bronchodilator or exercises is evaluated. It is a diagnostic test and does not constitute a treatment

94375

respiratory flow volume loop-es una documentación gráfica  de la información obtenida durante la realización de 94010 o 94060. Tiene criterios específicos para cuando se realiza.

The cpt codes94010 and 94060 you can not bill with 94375

The codes 94726,94727, and 94729 may be billed with codes 94010, 94060, 94375, as applicable.

Code 94640- Pressurized or non-pressurized inhalation treatment for acute airway obstruction of sputum induction for diagnostic purposes (eg, with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device)

Triple-S will recognize payment separately from code 94640 if the respiratory therapy service was for treatment of acute bronchospasm or for the induction of sputum production for diagnostic purposes. It will not be recognized for payment if the respiratory therapy service was performed as part of the spirometry test protocol (Ex: In spirometries with bronchodilator response where a pre and post bronchodilator spirometry is performed).

When the patient’s condition warrants billing of code 94375 and code 94640, the latter must be billed with MOD 59 in the form 1500 or electronically. The payment of this service will be subject to audit. Documentation that justifies payment separately from the service billed with MOD 59 must be legible and available in the patient’s file.

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