Ace your Pulmonary Function Testing Claims

Read answers to these two expert medical billing and coding questions and know the accurate CPT codes for pulmonary function testing.

Question: Your practice is interested in carrying out pulmonary function testing on asthma patients. How would you bill? 94010? 94016? Can you also charge a copayment? Is it worth buying a spirometry device?

Answer: CPT code for pulmonary function testing is essentially 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). A lot of many physicians consider they can bill 94010 for a hand held peak-flow meter, which has no code and is not distinctly billable.

You should not code 94016 (patient-initiated spirometric recording per 30-day period of time; physician review and interpretation only) lest the patient had a spirometer at home. The key to coding 94016 is carrying out the interpretation, whether you get reports over the phone lines from a rented machine in the patients home, or the patient brings printouts in.

The other CPT code for pulmonary function testing is 94060 (bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]). You should not use 94060 and 94010 on the same day. The bronchodilation is included in the 94060; do not bill for it distinctly.

Both 94060 and 94010 need a spirometer with a mechanism that shows results graphically. Whether it is worth buying one depends on the total asthma patients you have. A lot of pediatricians treat asthma without a spirometer; however, pediatricians who specialize in asthma and allergy could not get by without one. Primary care pediatricians should know that its not at all times easy to get good spirometry on younger children

Question: You have the CPT codes for the pulmonary function test (PFT) interpretations. However you are required to know if for a whole PFT study there is one code to bill with the modifier -26 (professional component), or should you bill for each procedure? For instance, in case a patient has complete PFTs (e.g., carbon monoxide diffusion capacity, and spirometry with bronchodilation, plethysmographic method), is there a particular code for the complete reading?

Answer: CPT code 94060 (bronchospasm evaluation; spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]) includes the following codes:

· 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation)

· 94200 (maximum breathing capacity, maximal voluntary ventilation)

· 94375 (respiratory flow volume loop)

· 94640 (nonpressurized inhalation treatment for acute airway obstruction)

· 94650 (intermittent positive pressure breathing IPPB) treatment, air or oxygen, with or without nebulized medication; initial demonstration and/or evaluation)

· 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation)

· 94770 (carbon dioxide, expired gas determination by infrared analyzer )

Bill all other CPT codes for the pulmonary function test distinctly. Append modifier -26 if services are carried out in a hospital and your physician is giving a written interpretation and report.

Check 3 Areas Before Selecting Your Ear Irrigation Code

69210 or E/M inclusion rests on service and provider.

A patient comes to your office, complaining of ear pain. The physician then orders ear irrigation. Can you legitimately report 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) for the care? Ask yourself these medical billing and coding questions to keep your irrigation claims in the clear.

Was It Simply Irrigation?

At times a provider can clear the patient’s ear with basic irrigation, however occasionally he requires using more extensive measures. Before selecting CPT® code 69210, verify the level of service provided.

You cannot bill 69210 in case the provider only does irrigation. There has to be use of certain type of instrumentation to ‘dig out’ the impaction.

Code 69210 is for removal of impacted cerumen, not an ear irrigation. In case the physician carries out just an irrigation, it’s included in the E/M service."

Prior to submitting 69210, the provider’s documentation must evidently show that he removed impacted cerumen. Procedure notes must include the following details:

• That the physician carried out the procedure;
• That the ear had impacted cerumen;
• Why the physician removed the cerumen;
• How the physician removed the cerumen (what tools he used, such as a scoop or curette);
• The outcome (canal cleared, could visualize eardrum, etc.).

In case you need to appeal the claim, the note you send must support the documentation stated above.

Medical Billing and Coding Tip: Some payers want you to append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M office visit code while you submit 69210 at the same encounter. Keep in mind that the E/M must only be billed when the work involved is distinctly identifiable and above and beyond the work involved in removing the impacted cerumen. The documentation of the E/M service must, preferably, be distinct from that of CPT® code 69210, and it must support the level of E/M service reported. Per CPT®, the E/M service may be stimulated by the symptom or condition (e.g. ear pain) for which the impacted cerumen removal was provided. Per se, dissimilar diagnoses are not needed for the E/M and 69210.

Who Carried Out the Service?

Before considering 69210, also confirm who treated the patient.

The physician should be performing the service to report 69210. Translation: Steer clear of CPT® code 69210 if the nurse cleans the ear.

Scenario: Imagine that a patient with ear pain sees the doctor, who recommends irrigation. The nurse performs the procedure after the physician sees the patient. The physician sees the patient again, to ensure that the ear canal is clean. Even though the physician saw the patient twice during the same office visit, he didn’t carry out the procedure. That implies that you’ll include the cleaning as part the E/M service, not a distinct procedure. CPT® code 69210 is intended to represent physician work.

Coding Tips: Refresher on CPT Codes 29826 Use To Reflect Add-On Status in 2012

Refer to codes for arthroscopic debridement while reporting only arthroscopic subacromial decompression.

CPT® 2012 transforms the way you’ll report arthroscopic acromioplasties, so you’ll want to make certain you’re informed on applying code +29826 (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament [i.e. arch] release, when performed [List separately in addition to code for primary procedure]), which is no longer an individual code. See the advice that follows for more on how to correctly report + 29826 plus CPT® codes for other primary procedures this year.

Document Additional Primary Procedures

The CPT® code +29826 transformed from a standalone to an add-on code in 2012, implying that you can now report this only when your surgeon carries out another scope procedure as the primary procedure.

Coders have been reporting code 29999 (Unlisted procedure, arthroscopy) while only an arthroscopic subacromial decompression of the shoulder was carried out.

Originally AAOS advised use of the unlisted procedure code 29999 while carrying out 29826 alone. Latest clarification from AMA/CPT is to use CPT® codes 29822 or 29823, depending upon the extent of debridement supported by the operative report.

While carrying out an arthroscopic acromioplasty alone, submission using the unlisted arthroscopy code of 29999 has been extensively practiced. The AMA has long stood by the theory that in case a correct code does not exist, the procedure must be submitted using the precise unlisted CPT® code.

This year’s change implies that you can now refer to 29822 (Arthroscopy, shoulder, surgical; debridement, limited) or 29823 (Arthroscopy, shoulder, surgical; debridement, extensive). Both the AMA and AAOS have issued statements that the suitable debridement code (29822 or 29823) must be reported while arthroscopic subacromial decompression is carried out as a standalone procedure.

The scope procedures that you may normally encounter for primary procedures are the arthroscopic claviculectomy, arthroscopic rotator cuff repair, arthroscopic debridement (debridement unrelated to the work performed for the decompression), or arthroscopic biceps tenodesis. The add-on code +29826 is permitted with CPT® codes 29806 -- 29825, 29827 and 29828. These are listed below:

• 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy)
• 29807 (Arthroscopy, shoulder, surgical; repair of SLAP lesion)
• 29819 (Arthroscopy, shoulder, surgical; with removal of loose body or foreign body)
• 29820 (Arthroscopy, shoulder, surgical; synovectomy, partial)
• 29821(Arthroscopy, shoulder, surgical; synovectomy, complete)
• 29822 (Arthroscopy, shoulder, surgical; debridement, limited)
• 29823 (Arthroscopy, shoulder, surgical; debridement, extensive)
• 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface [Mumford procedure])
• 29825 (Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation)
• 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair)
• 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis)

CPT 2012 Update: Ace Radiological Supervision With Vertebroplasties: Here’s How

You can report the professional component for your surgeon’s services.

In case your surgeon carries out vertebroplasties, a review of how to report radiological assistance your surgeon utilized will help you master the applicable CPT® codes and these claims.

Know When to Append Modifier 26

When carrying out a percutaneous vertebroplasty, your surgeon will use imaging in order to position the needle or to evaluate the injection technique. You report the radiological supervision with CPT® codes 72291 (Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation [sacroplasty], including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance) or 72292 (Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation [sacroplasty], including cavity creation, per vertebral body or sacrum; under CT guidance) depending upon whether your surgeon uses computed tomography (CT) in place of fluoroscopic guidance.

You append modifier 26 (Professional component) if the procedure is carried out in a facility setting. This has been historically distinctly reportable to account for conditions in which the imaging interpretation is carried out by a separate physician, usually a radiologist, from the physician carrying out the vertebroplasty. As per the trends in CPT®, the services may become bundled in case a significant majority of both services are carried out by the same physician.

Caveat: In case you append modifier 26, you should save a hard copy of the image(s), and you should dictate a distinct procedural report, and sign it (or electronically sign it) separately.

Coding example: In case your surgeon carries out vertebroplasty at T12 and L1 and uses fluoroscopic guidance, you report CPT® codes 22520 (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection; thoracic), 72291-26 and +22522 (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body [List separately in addition to code for primary procedure]).

Modifier 26 would be added for the provider’s claim if the provider owned the fluoroscopy equipment. If the equipment is physician owned, the full work value would be reported. CPT® codes 72291 and 72292 both carry a PT/TC indicator of "1", signifying that the procedures have both a technical and professional component.

In case your payer is Medicare, look out the edit for radiological supervision services. CPT® codes 72291 and 72292 are to be reported per segment. Medicare has an unlikely edit of "3" that is used for the radiological supervision services -- keep an eye out for this constraint for your Medicare carriers.

Grab Extra $368 in Ethical Reimbursement to Your Cyst Excision Claims

Mixing up branchial and preauricular cysts can put you in the wrong CPT section.

Unless you comprehend neck and ear anatomy, you could lose precious dollars for your otolaryngology practice. In case your ENT carries out a facial tissue transfer (14040) and you report branchial cleft cyst excision (42810) as an alternative, you’ll lose 10.82 relative value units -- which is $368 of lost revenue. Know if your vocab is up to par by examining the following operative report and also know what CPT codes apply.

Code This Excision

Procedure: Excision of left preauricular first branchial cleft sinus tract in a earlier operated field.

Pre-/postoperative diagnosis(es): Intermittent left preauricular first branchial cleft sinus tract.

Note: This procedure qualifies for modifier 22 as it is a revision surgery in a previously operated field.

Specimens sent to lab: Overlying skin as well as the deep sinus tract.

Indications for surgery: Intermittent left preauricular sinus tract.

Findings in surgery: Scarred preauricular areas from previous excision with no cutaneous fistula and no distinct sinus tract.

Procedure: … An incision was made with the #11 scalpel blade everywhere in the area that the parents had specified most recently drained. This area was above the tragal cartilage region. A portion of the tragal cartilage was transected as the deep plane of the excision. Then, dissection was performed inferiorly and superiorly besides anteriorly to eliminate this portion of the pretragal scar and deep tissue. The depth of the dissection was the parotid gland. It was obvious that there was a huge amount of scar tissue at the anterior excision site, and this was felt to also comprise branchial cleft sinus tissue. Consequently, additional excision of the scar was carried out with the #11 and #15 scalpels, and a huge portion of tissue removed down to and comprising a portion of the superficial aspect of the parotid gland....

Next to the removal of the specimen, a noteworthy defect was present in the preauricular region. The closure of this area needed undermining the facial skin inferior to the oracle and after that anteriorly about one-third to 40 percent of the way to the corner of the mouth and lateral canthus of the eye. After that the tissue advanced and portion of the tissue rotated to allow a closure in a parotidectomy or fascial fashion in the preauricular area with a T-segment going anteriorly at the level of the tragus. Plicating 3-0 chromic sutures were used to reduce the space made vacant by excision of the deep tissue. This closure of the deep space was made potential by advancing the adipose tissue posteriorly and superiorly. Yet again, this tissue was held in place with 3-0 chromic suture.

Check Cleft Type

Recognizing whether the cyst excision was in the neck or ear region evades using a CPT code from an incorrect CPT anatomy section.

Make ceratin that you don’t lump branchial and preauricular cysts. Each is from a different embryological source.

Link Branchial to Neck’s 42810-42815

For branchial cysts, you’ll be in the neck section. Brachial cleft cysts are congenital cysts that arise in the lateral aspect of the neck when the second branchial cleft fails to close during embryonic development. At about the fourth week of embryonic life, four branchial (or pharyngeal) clefts develop between five ridges termed as the branchial (or pharyngeal) arches. These arches and clefts contribute to the development of various structures of the head and neck.

You must use CPT code 42810 (Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues) once the branchial cyst is superficial. In case the provider dissects all the way to the tongue base or tonsillar pillars, you must report CPT code 42815 (Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx).

Think Ear for Preauricular Cyst

Preauricular cysts come from the six hillocks that form the external ear.

Result: You can’t use CPT code 42810 or 42815 for the above operative report. This is a preauricular sinus track, and you should use 42815 when the cyst is in the neck around the tonsil area.