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
J41.1, J44.9, J44.1, J44.0, J41.8, J42
J45.20, J45.22, J45.21, J45.20, J45.22, J45.21, J44.0, J44.1, J45.991, J45.909
Stenosis of Larynx
Other laryngeal conditions
Chronic airway obstruction
Fumes and vapors (chronic respiratory condition)
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
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:
Emphysema resulting from a procedure
Pulmonary Collapse – Allergy
J98.11, J98.19, J98.2, J98.3, J82, J81.0, J95.3, B44.81
Neoplasm of Respiratory System
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
Lymphangioma, any site
Involvement Systemic Sclerosis
Extrinsic allergic alveolitis
J67.0, J67.1, J67.2, J67.3, J67.4, J67.5, J67.6, J67.7, J67.8, J67.9
J60, J61, J62.8, J63.0, J63.1, J63.2, J63.3, J63.4, J63.5, J63.6
Unspecified alveolar and parietoalveolar pneumonopathy
Pulmonary alveolar proteinosis
Idiopathic pulmonary hemosiderosis
Pulmonary alveolar microlithiasis
B. Extrapulmonary lesions of:
Congenital musculoskeletal deformities of spine
Q67.5, Q76.3, Q76.425, Q76.426, Q76.427, Q76.428
· Acquired spondylolisthesis
· Pectus excavatum
· Current Tuberculosis
J86.9, J94.1, J94.8, J94.9, R09.1
· Myotonic disorders
· Paralytic syndromes
G83.81, G83.84, G83.89
· Peripheral neuropayhy
· Acute lateral sclerosis
C. Pulmonary vascular diseases:
· Other diseases of lung not elsewhere
D. Combined obstructive and destructive conditions:
· Respiratory conditions
· Heart failure
· Other diseases of lung
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)
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.
Medical records must document the medical necessity and the frequency of the tests.
This category of conditions refers to those in which the patient experiences symptoms sporadically or has symptoms without physical.
· Asthma equivalent/history of asthma with normal spirometry
· 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.
CPT 94070 is covered when invoiced with any previous ICD-10 code. Medical necessity must be documented.
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.
Bronchospasm evaluation; 94010 before and after bronchodilation or exercise
«Maximum Breathing Capacity, maximal voluntary ventilation».
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.
Ver +94729-Diffusing capacity Eg. Carbón monoxide,membrane
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:
«vital capacity, total (separate procedure)”
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).
Breathing response to CO2″ (CO2 response curve).
Breathing response to hypoxia» (hypoxia response curve).
Pulmonary Stress Testing. (ICD9-300.11)
Cover for blood gases and ear oximetry
Gases, blood, any combination of ph, pCO2, CO2, HCO2 (including calculated O2 saturation)
with O2 saturation by direct measurement, except pulse oximetry
Gases, blood, O2 saturation only, by direct measurement, except pulse oximetry
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.
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
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.