Reimbursement for Spirometry Procedures

• "Quick Guide" to Coding, Coverage and Payment for Spirometry
• What's New?
• General Information
• Spirometry - Hospital Outpatient Setting
• Coverage for Spirometry in the Physician Office Setting
• CPT Coding/Payment Guidelines
• ICD-9 Diagnosis Codes Supporting Medical Necessity for Spirometry Testing

"Quick Guide" to Coding, Coverage and Payment for Spirometry
To view our Quick Guide for Coding, Coverage and Payment ^**, please click here.

What's New?
Check back regularly for updates.

General Information
Spirometry is a component of pulmonary function testing (PFTs). PFTs describe several measurements designed to identify and quantify pulmonary impairments. Spirometry specifically measures forced vital capacity (FVC) and other measurements that can be obtained from FVC measurements.

Spirometry - Hospital Outpatient Setting
On August 1, 2000, a Hospital Outpatient Prospective Payment System (HOPPS) was introduced for payment of Medicare Hospital Outpatient procedures. Within the HOPPS, CPT procedure codes are categorized into an Ambulatory Payment Classification (APC) group, and each APC group is assigned a status indicator that defines how procedures in that category will be reimbursed.

Spirometry procedures are assigned the status indicator of “X” in the HOPPS. This means that these procedures are considered ancillary services for which payment is allowed. For payment rates and information, click on the code in the CPT Coding/Payment Guidelines section.

Coverage for Spirometry in the Physician Office Setting
Local coverage determinations (LCDs) have been written by many Medicare Part B carriers and, if available, may be obtained by contacting your Medicare Part B payer or by calling the Health Care Economics Department at (800) 645-2891. An example of general coverage indications are for diagnostic or monitoring purposes as described below (Source: Empire (New York) Medicare Pulmonary Function Testing Policy #PU002E03):

Diagnostic

• To evaluate symptoms, signs or abnormal laboratory tests
• Symptoms: unexplained dyspnea, wheezing, orthopnea, cough, phlegm production
• Signs: unexplained diminutive breath sounds, overinflation, cyanosis, chest deformity, unexplained crackles
• Abnormal laboratory tests: hypoxemia, hypercapnia, polycythemia, abnormal chest radiographs
• To measure the effect of systemic disease on pulmonary function (e.g. neuromuscular disease, connective tissue disease)
• To assess preoperative risk
• To assess prognosis (lung transplant, etc.)

• To assess therapeutic interventions:
• Bronchodilator therapy
• Steroid treatment for asthma, interstitial lung disease, etc.
• Other (antibiotics in cystic fibrosis, etc.)
• To monitor for adverse reactions to drugs with known pulmonary toxicity

CPT Coding and Medicare Payment Guidelines
The following are the procedure codes most commonly associated with spirometry procedures performed by the Renaissance and Simplicity spirometers. Note the Simplicity spirometer will not perform a respiratory flow volume loop.
For payment information, click on code.

* Existence of coding does not guarantee coverage or payment for any procedure by any payer. Medical necessity for the procedure must be established by the patient's physician in accordance with specific payer guidelines.

ICD-9 Diagnosis Codes Supporting Medical Necessity for Spirometry Testing
A listing of ICD-9 codes that help to support the medical necessity for spirometry testing is borrowed from the Empire Medicare Services (New York) Pulmonary Function Testing Policy #PU002E03:

TRUNCATED DIAGNOSIS CODES ARE NOT ACCEPTABLE.

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the service was performed.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid.

D. CPT codes 94250, 94260, 94350, 94360, 94370, 94400, 94450, 94680, 94681, 94690, 94750 and 94770
These procedure codes are payable with any diagnosis from sections A, B or C.

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CPT Only^® 2004 American Medical Association All Rights Reserved.
Existence of coding does not guarantee coverage or payment for any procedure by any payer.
Medical necessity for the procedure must be established by the patient's physician in accordance with specific payer guidelines.

The information that is being provided is for general information and should not be relied upon as definitive or comprehensive. All coding information is related to Medicare claims only. Medicaid agencies may utilize their own coding systems. Coverage rules may change from time to time. When seeking definitive information regarding coding or reimbursement it is always best to confer with your local Medicare office.

For additional information, contact our Reimbursement Department at 1-800-645-2891.

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