Medical coding can feel overwhelming, right? Hundreds of codes, tons of modifiers, and payer guidelines that change all the time. It’s enough to make any pulmonology practice struggle to stay in the black.
But if you’re looking for a reliable resource on CPT code 94010, you’ve landed in the right spot. This guide dives deep into spirometry coding, covering everything from the specifics of 94010 to its proper use and crucial billing and reimbursement tips. Whether you are a physician handling billing yourself or just starting with pulmonary function testing, this will be your go-to guide.
So, let’s jump right in!
CPT Code 94010 – Description
CPT code 94010 falls within the ‘Pulmonary Diagnostic Testing and Therapies’ code range, as defined by the American Medical Association (AMA). It covers a spirometry test without bronchodilator administration. A technician or healthcare provider performs the spirometry test to evaluate the patient’s respiratory function.
Here’s how it works! The spirometer, a medical device, is the main component of the procedure. It connects to a computer that records the maximum expired air (total and timed vital capacity) and speed of expiration (expiratory flow rate).
Essentially, it measures the volume of air inhaled or exhaled by the lungs. The computer displays the results in a graph. The test typically involves a rapid 12- to 15-second exhalation after a deep inhalation.
Scenarios Where CPT Code 94010 is Applicable
The following are some practical scenarios where CPT code 94010 is applicable:
Suspected Asthma Evaluation
Imagine a patient who visits the clinic with a whooping cough, wheezing, and shortness of breath. Besides, these symptoms flare up after being around allergens or during exercise.
So, the physician starts with a physical exam. The provider hears mild wheezing when listening to the patient’s lungs. The clinician suspects exercise-induced and allergy-related asthma. That’s why the physician orders spirometry without a bronchodilator to confirm the diagnosis.
CPT code 94010 applies here for reporting the spirometry procedure.
COPD Monitoring
Picture this: a retired construction worker, a long-time smoker with diagnosed chronic obstructive pulmonary disease (COPD), comes in for his regular three-month check-up. This time, he complains of increased shortness of breath with minimal exertion and coughing up thick, yellow sputum.
The physician requests spirometry without a bronchodilator to monitor the patient’s current lung function. The results of this study enable the physician to update the medication regime and evaluate a possible exacerbation.
Thus, CPT code 94010 applies.
Preoperative Pulmonary Function Assessment
Consider an eighty-year-old woman with a history of hypertension and mild congestive heart failure. She is scheduled for a hip replacement surgery following a fall.
Therefore, the surgeon orders a preoperative pulmonary function assessment to evaluate her respiratory status and identify any potential risks with anesthesia and surgery.
However, the anesthesiologist is concerned about her ability to tolerate general anesthesia due to her age and medical history.
As a result, they perform spirometry (CPT code 94010) to assess her lung volumes and airflow.
Applicable Modifiers for CPT Code 94010
Listed below are all the applicable modifiers:
Modifier 25
What happens when a physician renders a significant, separately identifiable E/M service on the same day as spirometry? Modifier 25 applies to the E/M service code for separate billing.
Modifier 26
Spirometry is a global procedure that contains technical (equipment use and technician’s time) and professional (interpretation and report preparation) components. You will be reimbursed for both if you report CPT code 94010 without a modifier.
However, append modifier 26 if you have only interpreted the spirometry findings and prepared a written report. This modifier helps ensure fair reimbursement against your rendered services.
Modifier TC
Report CPT 94010 with modifier TC to bill solely for the technical component of the spirometry procedure. This modifier indicates you are billing for the equipment, personnel, and service performance.
Modifier 52
Occasionally, the physician might partially reduce or discontinue the spirometry procedure. When this occurs, you will not receive full reimbursement. Therefore, append modifier 52 with CPT code 94010 to ensure rightful reimbursement.
Modifier 53
There may be instances where the physician terminates the spirometry procedure due to unforeseen circumstances. Append modifier 53 as it indicates discontinued service.
Modifier 76
When the same physician repeats the spirometry procedure on the same day, duplication errors may lead to a claim denial. However, appending modifier 76 will identify that the repetition was necessary and eligible for a separate reimbursement.
Modifier 77
Sometimes, a different healthcare professional repeats the spirometry procedure on the same day. For example, if the initial report was inconclusive, a repeat test is needed. If a different physician repeats the service, you must append modifier 77 with the CPT code 94010.
CPT Code 94010 vs. 94060
Below is an at-a-glance table comparing the two CPT codes:
| CPT Code 94010 | CPT Code 94060 | |
|---|---|---|
| Description | Spirometry, including graphic record, total and timed vital capacity, and expiratory flow rate measurement(s), with or without maximal voluntary ventilation. | Bronchodilation responsiveness, spirometry as in 94010, pre and post-bronchodilator administration. |
| Bronchodilator Use | No | Yes, with pre and post-bronchodilator administration. |
| Measurements | Single or multiple | Multiple measurements. Pre-bronchodilator; during bronchodilator administration, and post-bronchodilator administration measurement. |
| Coding | Reported as one unit, whether one or more spirometry measurements occurred. | Reported as one unit, encompassing the pre, during, and post-bronchodilator phases. |
Both procedural codes cover the spirometry study to measure lung function. However, the core distinction lies in whether a bronchodilator is involved.
Just so we are all on the same page! A bronchodilator is a medication that opens up the airways in the lungs. How? It relaxes the muscles that tighten around the bronchial tubes, making breathing easier.
Now, let’s get back to comparing CPT codes 94010 and 94060!
CPT 94010 is for basic spirometry. It can include single or multiple measurements but no bronchodilator.
On the flip side, the CPT 94060 descriptor specifically mentions covering the bronchodilation responsiveness testing. It encompasses pre-bronchodilator measurements, bronchodilator administration, and post-bronchodilator measurements.
Remember, both codes are reported as a single unit, regardless of how many individual measurements you take within the described service.
So, the key to accurate coding is checking the clinical documentation to see if the spirometry involved bronchodilator administration. If so, use CPT code 94060. If not, use 94010.
CPT Code 94010 – Billing & Reimbursement Guidelines
Here are the billing and reimbursement guidelines for CPT code 94010:
Understand Varying Reimbursement Rates
The reimbursement rate for the spirometry procedure without a bronchodilator can vary significantly based on multiple factors. These may include the insurance payer (Medicare, Medicaid, other commercial payers), state, and specific contract agreements.
Thus, always check with the payer and review contract agreements and state-related policies to acquire more information on the reimbursement rate.
Prove Medical Necessity
Regardless of the payer, establishing the medical necessity of the rendered spirometry study is mandatory to support reimbursement.
Ensure Correct Code Pair
Use CPT code 94010 with the appropriate ICD-10 diagnosis code. Your physician’s diagnosis must support the need for the spirometry test, which is crucial for establishing medical necessity.
Maintain Comprehensive Documentation
Complete and accurate documentation is essential. This includes the patient’s medical history, reason for the test, clinical notes, procedure details, test results, and interpretation.
Append Appropriate Modifiers
As discussed earlier, modifiers are used in specific situations. For instance, append the modifier TC to bill for equipment, personnel, and spirometry performance. Use modifier 26 to indicate results interpretation and report preparation only.
Other applicable modifiers are 25, 52, 53, 76, and 77. You can refer to the ‘Applicable Modifiers for CPT Code 94010’ section for more information on modifier usage.
Summary
It is now time to wrap up this detailed guide. However, before concluding, let’s quickly summarize everything we learned. We explained that the CPT code 94010 covers the spirometry without bronchodilation administration.
We also shared some scenarios where this CPT code applies. These examples include preoperative pulmonary function assessment, COPD monitoring, and suspected asthma evaluation.
Moving forward, we listed down some applicable modifiers, including modifiers 25, 26, TC, 52, 53, 76, and 77. We also compared the CPT 94010 with CPT 94060. That’s not all. We discussed the billing and reimbursement guidelines related to CPT 94010. Not sure how to handle the billing intricacies in-house? Outsource pulmonology billing services to professionals at MediBillMD and experience the ultimate financial success.
