The evaluation of lung function is indicated to determine:
- The presence of lung disease or abnormality of lung function.
- The extent of abnormalities and the potential causative disease process.
- The extent of disability due to abnormal lung function.
- The progression of the disease.
- The type of disease or lesion.
- The response to a course of therapy in the treatment of the particular condition.
- The presence of lung disease or abnormality of lung function secondary to toxicity of medication.
Limitations:
- For the purposes of medical reviews, the carrier expects the provider to follow a thoughtful, purposeful sequence in his selection of tests.
- Provision of services described by CPT codes 94011, 94012 and 94013 must be accomplished with a physician in attendance at the bedside. Medicare will not cover these services if provided by an IDTF.
- The Medicare program specifically excludes screening testing. Examples of screening also include, but are not limited to:
- An asymptomatic patient, with or without high risk of lung disease.
- Studies as part of a routine exam.
- Studies as part of an epidemiological survey:
- Procedure code 94150 is a “bundled” service, which means there is no separate reimbursement for this code.
- CPT codes 94014, 94015 and 94016 are not covered since their clinical efficacy has not been established.
- The following summary algorithm is a useful guide that may be considered in medical necessity reviews.
Spirometry
Indications
Spirometry makes up the most commonly applied section of Pulmonary Function Testing (PFT). General indications are:
Spirometry makes up the most commonly applied section of Pulmonary Function Testing (PFT). General indications are:
Diagnostic
- To evaluate symptoms, signs or abnormal laboratory tests:
- Symptoms: unexplained dyspnea, wheezing, orthopnea, cough or phlegm production.
- Signs: unexplained decreased breath sounds, overinflation, cyanosis, chest deformity, wheezing or unexplained adventitious sounds.
- Abnormal laboratory tests: hypoxemia, hypercapnia, polycythemia or abnormal chest radiographs.
- To measure the effect of systemic disease on pulmonary function (e.g., neuromuscular disease and connective tissue disease).
- To assess preoperative risk.
- To assess prognosis (lung transplant, etc.).
Monitoring
- To assess therapeutic interventions:
- Bronchodilator therapy.
- Steroid treatment for asthma, interstitial lung disease, etc.
- Other, such as antibiotics in cystic fibrosis.
- To monitor for adverse reactions to drugs with known pulmonary toxicity.
Limitations:
Post-bronchodilator spirometry is used to rule out a reversible component to a patient’s bronchospasm and determine if the patient is a candidate for bronchodilator therapy. Claims for code 94060 will be covered when at least one of the following conditions is present and documented in the medical record:
Post-bronchodilator spirometry is used to rule out a reversible component to a patient’s bronchospasm and determine if the patient is a candidate for bronchodilator therapy. Claims for code 94060 will be covered when at least one of the following conditions is present and documented in the medical record:
- There are signs or symptoms consistent with bronchospasm.
- Spirometry without bronchodilator is abnormal.
- Reversibility of bronchospasm in response to bronchodilator therapy, or lack thereof, has not yet been demonstrated.
If reversibility of bronchospasm (bronchodilator responsiveness) has already been either ruled out or demonstrated, repeat pre- and post-bronchodilator study (94060) will be covered only when there is a significant clinical change in the patient’s functional respiratory status necessitating an adjustment or augmentation of bronchoactive medications, and this is documented in the patient’s medical record.
Lung Volumes
The absolute lung volumes or capacities cannot be measured by spirometry. They are Total Lung Capacity (TLC), Residual Volume (RV) and Functional Residual Capacity (FRC). Measurement of these volumes or capacities is indicated when the vital capacity is reduced. Lung volumes may also be indicated to:
Lung Volumes
The absolute lung volumes or capacities cannot be measured by spirometry. They are Total Lung Capacity (TLC), Residual Volume (RV) and Functional Residual Capacity (FRC). Measurement of these volumes or capacities is indicated when the vital capacity is reduced. Lung volumes may also be indicated to:
- Distinguish restrictive disease from COPD.
- Evaluate bullous diseases and elucidate the date from other lung functions.
- Assess therapeutic interventions, such as lobectomy and chemotherapy.
Diffusion Capacity (DLCO)
Diffusion capacity (DLCO) measurement is often indicated when spirometry and lung volume studies reveal restrictive disease. DLCO is used to help distinguish between an intrinsic pulmonary process, such as interstitial lung disease and emphysema, and an extrapulmonary process, such as chest wall and neuromuscular disorders. Diffusion capacity is also useful in quantifying the degree of parenchymal destruction in COPD, and assessing pulmonary vascular diseases and interstitial diseases, even if vital capacity is normal.
Diffusion capacity (DLCO) measurement is often indicated when spirometry and lung volume studies reveal restrictive disease. DLCO is used to help distinguish between an intrinsic pulmonary process, such as interstitial lung disease and emphysema, and an extrapulmonary process, such as chest wall and neuromuscular disorders. Diffusion capacity is also useful in quantifying the degree of parenchymal destruction in COPD, and assessing pulmonary vascular diseases and interstitial diseases, even if vital capacity is normal.
Lung Compliance
Lung compliance measures the elastic recoil or stiffness of the lungs. It is more invasive than other PFTs, because the patient is required to swallow an esophageal balloon. Compliance studies are performed only when all other PFTs give equivocal results or the results require confirmation by additional data. Lung compliance may be increased in emphysema and reduced in interstitial lung disease.
Lung compliance measures the elastic recoil or stiffness of the lungs. It is more invasive than other PFTs, because the patient is required to swallow an esophageal balloon. Compliance studies are performed only when all other PFTs give equivocal results or the results require confirmation by additional data. Lung compliance may be increased in emphysema and reduced in interstitial lung disease.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 21X, 22X, 23X, 71X, 73X, 75X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD . Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.
046X, 0410, 0412 and 0419
CPT/HCPCS Codes
Note:
|
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
|
94010©
|
Breathing capacity test
|
94011©
|
Up to 2 yrs old, spirometry
|
Note: Use code 94011 for infant and child.
|
|
94012©
|
= 2 yrs, spiromtry w/dilator
|
Note: Use code 94012 for infant and child.
|
|
94013©
|
= 2 yrs, lung volumes
|
Note: Use code 94013 for infant and child.
|
|
94014©
|
Patient recoded spirometry
|
94015©
|
Patient recorded spirometry
|
94016©
|
Review patient spirometry
|
94060©
|
Evaluation of wheezing
|
94070©
|
Evaluation of wheezing
|
94200©
|
Lung function test (mbc/mvv)
|
94240©
|
Residual lung capacity
|
94250©
|
Expired gas collection
|
94260©
|
Thoracic gas volume
|
94350©
|
Lung nitrogen washout curve
|
94360©
|
Measure airflow resistance
|
94370©
|
Breath airway closing volume
|
94375©
|
Respiratory flow volume loop
|
94400©
|
Co2 breathing response curve
|
94450©
|
Hypoxia response curve
|
94680©
|
Exhaled air analysis, o2
|
94681©
|
Exhaled air analysis, o2/co2
|
94690©
|
Exhaled air analysis
|
94720©
|
Monoxide diffusing capacity
|
94750©
|
Pulmonary compliance study
|
94770©
|
Exhaled carbon dioxide test
|
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 94010, 94060, 94200, 94240, 94250, 94260, 94350, 94360, 94370, 94375, 94400, 94450, 94680, 94681, 94690, 94720, 94750 and 94770:
Covered for:
011.00–011.06
|
Pulmonary tuberculosis
|
011.10–011.16
|
Pulmonary tuberculosis
|
011.20–011.26
|
Pulmonary tuberculosis
|
011.30–011.36
|
Pulmonary tuberculosis
|
011.40–011.46
|
Pulmonary tuberculosis
|
011.50–011.56
|
Pulmonary tuberculosis
|
011.60–011.66
|
Pulmonary tuberculosis
|
011.70–011.76
|
Pulmonary tuberculosis
|
011.80–011.86
|
Pulmonary tuberculosis
|
011.90–011.96
|
Pulmonary tuberculosis
|
012.00–012.06
|
Other respiratory tuberculosis
|
012.10–012.16
|
Other respiratory tuberculosis
|
012.20–012.26
|
Other respiratory tuberculosis
|
012.30–012.36
|
Other respiratory tuberculosis
|
012.80–012.86
|
Other respiratory tuberculosis
|
031.0
|
Pulmonary diseases, due to other mycobacteria
|
039.1
|
Actinomycotic infections, pulmonary
|
045.00–045.03
|
Acute poliomyelitis
|
114.0
|
Primary coccidioidomycosis (pulmonary)
|
116.0
|
Blastomycosis
|
117.1
|
Sporotrichosis
|
117.5
|
Cryptococcosis
|
135
|
Sarcoidosis
|
138
|
Late effects of acute poliomyelitis
|
162.0
|
Malignant neoplasm of trachea
|
162.2–162.5
|
Malignant neoplasm of trachea, bronchus and lung
|
162.8–162.9
|
Malignant neoplasm of trachea, bronchus and lung
|
163.0–163.1
|
Malignant neoplasm of parietal pleura
|
163.8–163.9
|
Malignant neoplasm of parietal pleura
|
164.0–164.3
|
Malignant neoplasm of thymus, heart, and mediastinum
|
164.8–164.9
|
Malignant neoplasm of thymus, heart, and mediastinum
|
165.0
|
Malignant neoplasm of upper respiratory tract, part unspecified
|
165.8–165.9
|
Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs
|
197.0
|
Secondary malignant neoplasm of lung
|
212.3–212.5
|
Benign neoplasm of respiratory and intrathoracic organs
|
228.1
|
Lymphangioma, any site
|
231.2
|
Carcinoma in situ of bronchus and lung
|
235.7
|
Neoplasm of uncertain behavior of trachea, bronchus and lung
|
239.1
|
Neoplasms of unspecified nature of the respiratory system
|
277.00–277.01
|
Other and unspecified disorders of metabolism
|
277.81–277.84
|
Other specified disorders of metabolism
|
277.89
|
Other specified disorders of metabolism
|
289.0
|
Polycythemia, secondary
|
335.20
|
Amyotrophic lateral sclerosis
|
344.89
|
Other specified paralytic syndrome
|
357.0
|
Acute infective polyneuritis (Guillain-Barré syndrome)
|
358.00–358.01
|
Myasthenia gravis
|
359.1
|
Hereditary progressive muscular dystrophy
|
415.11- 415.12
|
Pulmonary embolism and infarction
|
415.19
|
Other pulmonary embolism and infarction
|
416.0–416.2
|
Chronic pulmonary heart disease
|
416.8–416.9
|
Chronic pulmonary heart disease
|
428.0–428.1
|
Heart failure
|
428.20–428.23
|
Systolic heart failure
|
428.30–428.33
|
Diastolic heart failure
|
428.40–428.43
|
Combined systolic and diastolic heart failure
|
428.9
|
Heart failure, unspecified
|
446.20–446.21
|
Hypersensitivity angiitis
|
446.29
|
Other unspecified hypersensitivity angiitis
|
466.0
|
Acute bronchitis
|
466.11
|
Acute bronchiolitis due to respiratory syncytial virus (RSV)
|
466.19
|
Acute bronchiolitis due to other infectious organisms
|
480.3
|
Pneumonia due to SARS-associated coronavirus
|
490
|
Bronchitis, not specified as acute or chronic
|
491.0–491.1
|
Chronic bronchitis
|
491.20–491.21
|
Obstructive chronic bronchitis
|
491.22
|
Obstructive chronic bronchitis with acute bronchitis
|
492.0
|
Emphysematous bleb
|
492.8
|
Other emphysema
|
493.00–493.02
|
Asthma
|
493.10–493.12
|
Asthma
|
493.20–493.22
|
Asthma
|
493.81–493.82
|
Other forms of asthma
|
493.90–493.92
|
Asthma, unspecified
|
494.0–494.1
|
Bronchiectasis
|
495.0–495.9
|
Extrinsic allergic alveolitis
|
496
|
Chronic airway obstruction, not elsewhere classified
|
500–505
|
Pneumoconioses and other lung diseases due to external agents
|
508.1
|
Chronic and other pulmonary manifestations due to radiation
|
508.8–508.9
|
Respiratory conditions due to other and unspecified external agents
|
511.0
|
Pleurisy without mention of effusion or current tuberculosis
|
511.81
|
Malignant pleural effusion
|
511.89
|
Other specified forms of effusion, except tuberculous
|
515
|
Postinflammatory pulmonary fibrosis
|
516.3
|
Idiopathic fibrosing alveolitis
|
516.8
|
Other specified alveolar and parietoalveolar pneumonopathies
|
517.2
|
Lung involvement in systemic sclerosis
|
517.8
|
Lung involvement in other diseases classified elsewhere
|
518.0
|
Pulmonary collapse
|
518.7
|
Transfusion related acute lung injury (TRALI)
|
518.81
|
Acute respiratory failure
|
518.89
|
Other diseases of lung, not elsewhere classified (chronic pulmonary vascular occlusive disease)
|
519.11
|
Acute bronchospasm
|
519.19
|
Other diseases of trachea and bronchus
|
519.4
|
Disorders of diaphragm
|
519.8
|
Other diseases of respiratory system, not elsewhere classified
|
710.0
|
Systemic lupus erythematosus
|
714.81
|
Rheumatoid lung
|
737.10
|
Kyphosis (acquired) (postural)
|
737.30
|
Scoliosis [and kyphoscoliosis], idiopathic
|
754.2
|
Congenital musculoskeletal deformities of spine
|
754.81
|
Pectus excavatum
|
780.50–780.59
|
Sleep disturbances
|
782.5
|
Cyanosis
|
786.00–786.07
|
Dyspnea and respiratory abnormalities
|
786.09
|
Other dyspnea and respiratory abnormality
|
786.1–786.2
|
Symptoms involving respiratory system and other chest symptoms
|
790.91
|
Abnormal arterial blood gases
|
793.1
|
Nonspecific (abnormal) findings on radiological and other examination of lung field
|
799.01-799.02
|
Other ill-defined and unknown causes of morbidity and mortality, asphyxia (hypoxemia)
|
909.5
|
Late effect of adverse effect of drug, medicinal or biological substance
|
987.0–987.9
|
Toxic effect of other gases, fumes, or vapors
|
998.81
|
Emphysema (subcutaneous) (surgical) resulting from a procedure
|
V12.60–V12.61
|
Diseases of respiratory system
|
V12.69
|
Other diseases of respiratory system
|
V42.1
|
Heart replaced by transplant
|
V42.6
|
Lung replaced by transplant
|
V58.63
|
Long-term (current) use of antiplatelet/antithrombotic
|
V58.69
|
Long-term (current) use of other medications
|
Medicare is establishing the following limited coverage for CPT/HCPCS code 94070:
Covered for:
493.01
|
Extrinsic asthma with status asthmaticus
|
493.10
|
Intrinsic asthma, unspecified
|
493.11
|
Intrinsic asthma with status asthmaticus
|
493.20
|
Chronic obstructive asthma, unspecified
|
493.81
|
Exercise induced bronchospasm
|
493.82
|
Cough variant asthma
|
493.90
|
Asthma, unspecified, unspecified
|
493.91
|
Asthma, unspecified type, with status asthmaticus
|
493.92
|
Asthma, unspecified, with (acute) exacerbation
|
518.7
|
Transfusion related acute lung injury (TRALI)
|
518.89
|
Other disease of lung, not elsewhere classified (bronchial allergy/hypersensitivity)
|
786.05
|
Shortness of breath
|
786.2
|
Cough (unexplained)
|
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Note: Limited coverage is not being established at this time for CPT codes 94011, 94012 or 94013.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
V70.0
|
Routine general medical examination at a health care facility
|
V70.6
|
Health examination in population surveys
|
V70.7
|
Examination of participant in clinical trial
|
V72.82
|
Preoperative respiratory examination
|
V76.0
|
Special screening for malignant neoplasms of the respiratory organs
|
V81.3
|
Screening for chronic bronchitis and emphysema
|
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
- Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
- All providers of pulmonary function tests should have a referral (a prescription) with clinical diagnoses and requested tests on file. Indications for the studies should be clearly described in clinical records and available for review.
- All equipment and studies should meet minimum standards outlined by the American Thoracic Society.
- Spirometry studies, in particular, require a minimum of three attempts that must meet minimum acceptability criteria.
- All studies require an interpretation with a written report. Computerized reports must have a physician’s signature attesting to their accuracy.
Appendices
N/A
Utilization Guidelines
Medicare would not expect to see most of the services in this LCD billed more than once annually and would not expect to see many of the services billed more than once in total.
Some patients, such as those under treatment for pulmonary fibrosis (ICD-9-CM diagnosis codes 515 or 516.3) may require more than one episode of respiratory testing each year, perhaps up to four times per year. For Medicare to cover repeated testing, medical necessity must be justifiable upon consideration of both the clinical condition of the patient and the expected clinical utility of the information that will be obtained from the testing. The patient’s record must clearly document diagnoses and conditions that necessitate repeated testing and such documentation must be available to Medicare upon request.
Some patients, such as those under treatment for pulmonary fibrosis (ICD-9-CM diagnosis codes 515 or 516.3) may require more than one episode of respiratory testing each year, perhaps up to four times per year. For Medicare to cover repeated testing, medical necessity must be justifiable upon consideration of both the clinical condition of the patient and the expected clinical utility of the information that will be obtained from the testing. The patient’s record must clearly document diagnoses and conditions that necessitate repeated testing and such documentation must be available to Medicare upon request.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
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How much does Medicare pay in dollars for a complete PFT?