Spirometry Billing (A Reimbursement Guide)

Who should have Spirometry Testing? In earlier times there was no any real concept that how to get reimbursement against the spirometry. Afterwards, in 1994, the American Thoracic Society published an official statement of “Standardization of Spirometry.” In this statement there was seen a potential indications for Spirometry, some of which may not be covered by Medicare or other payors:

• To assess therapeutic interventions (e.g., bronchodilator therapy, steroid treatment, management of CHF, etc.)


• To assess preoperative risk


• To screen individuals at risk of having pulmonary diseases (e.g., smokers, occupational exposures)*


• To assess health status before enrollment in strenuous physical activity programs*


• To assess patients as part of a rehabilitation program*


• To assess risks as part of an insurance evaluation*


• To assess individuals for legal reasons (e.g., Social Security. personal injury lawsuits)*

*These Indications are generally not covered by Medicare. What Codes describe spirometry procedures? What are the associated payment rates? The current Procedural Terminology (CPT) codes defined below are the most common codes used to describe spirometry procedures performed. The simplicity Spirometer does not perform a respiratory flow volume loop (CPT code 94375). Note: According to the Centers for Medicare and Medicaid Service (CMS) Correct Coding Initiative, none of the procedures described by the CPT codes listed below may be billed together on the same date of service. Please consult the latest version of the National Correct Coding Policy Manual to identify rebundling combinations. Edits may be reviewed at www.cms.hhs.gov/physicians/cciedits/default.asp

CPT Code **	Description	Unadjusted 2005 Medicare Allowable***
94010 (may not be billed with 94060 or 94375 on same DOS)	Breathing capacity test	$33
94060 (may not be billed with 94010 or 94375 on same DOS)	Evaluation of wheezing (pre-and post-bronchodilator)	$55
94375 (may not be billed with 94060 or 94375 on same DOS)	Respiratory flow volume loop	$36

** Most commonly used CPT codes for spirometry. Additional codes may be found in the Current Procedural Terminology (CPT) Manual published by the American Medical Association. All spirometers may not perform all procedures identified by CPT codes. The existence of CPT codes does not guarantee coverage of payment for any device by any insurance carrier of Medicare. Medical necessity must be established by the patient’s physician in accordance with specific coverage policy guidelines. *** Medicare allowable amounts vary by geographic region. What documentation is needed to support payment for spirometry procedures? Many Medicare Part B carriers have published Local Medical Review Policies (LMRP) that describe specific coverage guidelines for spirometry procedures. For example Upstate Medicare in New York offers the following list of ICD-9 codes, which may help support the medical necessity for spirometry testing. These codes may not be applicable in other regions of the country. For definitive coverage and payment information contact your local Part B carrier. What are general coverage guidelines for spirometry under the Medicare Program? · Local Medical Review Policies have been written by many Part B carriers, and copies may be requested through customer’s local Medicare Part B Carrier. · The appropriate combination of tests may be coded if proper clinical indication exists. Consult local medical necessity policy for Correct Coding guidelines and unbundling information. · The Medicare Program specifically excludes coverage for screening tests, including;

• Spirometric assessment of an asymptomatic patient, with or without high risk of lung disease;


• Studies as part of a routine examination; and


• Studies as part of an epidemiologic survey.

Reference:

1. American Thoracic Society (1995). Standardization of spirometry, 1994 update. Am J Respir Crit Care Med. 1995;152:1107-1136.


2. American Medical Association. Current Procedural Terminology. Professional Edition.


3. Physician fee Schedule: payment policies and relative units. Federal Register Vol. 69, No. 219, November 15, 2004.


4. Local Medical Review Policy. Pulmonary Function Testing. 2003. Update Medicare Division, New York.


5. American Medical Association. International Classification of Diseases, ICD-9-CM.