Exercise-Induced Bronchospasm*
Coding and Billing for Physician Services
Carol Pohlig, BSN, RNPhysician reporting of the service to insurance companies for reimbursement is multifaceted and perplexing to those who do not understand the factors to consider. Test selection should be individualized based on the patient’s history and/or needs. Federal regulations concerning physician supervision of diagnostic tests mandate different levels of physician supervision based on the type and complexity of the test. Many factors play a key role in physician claim submission. These include testing location, component services, coding edits, and additional visits. Medical necessity of the service(s) must also be demonstrated for payer consideration and reimbursement. The following article reviews various tests for exercise-induced bronchospasm and focuses on issues to assist the physician in reporting the services accurately and appropriately.
(CHEST 2009; 135:210 –214) Key words:bronchoprovocation evaluation; bronchospasm; bronchospasm provocation evaluation; exercise-induced bronchospasm; eucapnic voluntary hyperventilation; evaluation and management; exercise stress test; medical necessity; Medicare; National Correct Coding Initiative; physician billing; practice management; pulmonary stress test; reimburse-ment; spirometry
Abbreviations: CPT⫽current procedural terminology; EIB⫽exercise-induced bronchospasm; E/M⫽evaluation and management; EVH⫽eucapnic voluntary hyperventilation; ICD-9-CM⫽International Classification of Diseases, Ninth Edition, Clinical Modification; MPFS⫽Medicare Physician Fee Schedule; TC⫽technical component
T
he National Asthma Education and Prevention Program defines exercise-induced bronchos-pasm (EIB) as the presence of symptoms in relation to athletic performance or a significant decrease in FEV1in relation to exercise, typically occurring afterseveral minutes of vigorous physical activity and reaching its nadir within 5 to 10 min.1Many
individ-uals do not have symptoms at rest or in the absence of strenuous activity. EIB often goes undiagnosed because most people attribute their symptoms to other causes (eg, deconditioning, situational fatigue) and do not seek medical advice. Patients who
com-plain of exertional dyspnea may demonstrate a nor-mal response to spirometry, prompting further in-vestigation. Physicians may be well aware of the testing methods, selection, implementation, and data analysis related to EIB evaluations, but claim sub-mission to insurance companies for appropriate re-imbursement is multifaceted and perplexing to those who do not consider the various factors.
Testing
EIB triggers may involve an accelerated exchange of heat, water vapor, or both between airway mucosa and inspired air.2 The prevalence and severity of
bronchoconstriction increases with the inspiration of colder and dryer air, and with the intensity of ventilatory response.2 Different techniques for EIB
testing exist. The more commonly used methods are exercise (treadmill, cycle ergometer, or field-based exercise), current procedural terminology (CPT) 94620, 94621; and bronchoprovocation (methacho-line, cold air), CPT 94070. Test selection should be individualized to the patient’s history and/or needs, *From the Department of Medicine, University of Pennsylvania
Health System, Philadelphia, PA.
The author has no personal or financial conflicts associated with this article to disclose.
Manuscript received January 31, 2008; revision accepted July 25, 2008.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml).
Correspondence to: Carol Pohlig, BSN, RN, University of Penn-sylvania Medical Center, 3400 Spruce St, 100 Centrex, Philadel-phia, PA 19104; e-mail: [email protected]
DOI: 10.1378/chest.08-0298
replicating the activity or exposure when patients experience EIB. Consideration of these factors in-creases the efficacy and reliability of the selected test method. For example, exercise in the field has proven to be a better EIB predictor than laboratory-based exercise, yet field testing has limitations such as environmental variability, and uncontrolled varia-tions in exercise intensity.3The financial implications
and space limitations for some private practices may affect the type of equipment used during exercise testing (eg, treadmill vs exercise bicycle) that can impact ventilatory response. In fact, some studies4
have proven the inferiority of cycle testing despite its cost-effectiveness. Pharmacologic challenge tests, such as methacholine or histamine, have shown a lower sensitivity than eucapnic voluntary hyperven-tilation (EVH) for the detection of EIB in elite athletes.5 However, EVH produces a ventilation
higher than most individuals would normally achieve during exercise and may overdiagnose EIB in non-athletes. Therefore, methacholine or histamine chal-lenges are more sensitive and preferred for the average individual3,4,6 Ultimately, cost and
reim-bursement comparisons may dictate the broncho-provocation method employed.
A pretest evaluation (brief history, with or without a brief examination of the chest and lungs) should occur. This guides physician selection of the appro-priate testing method and identifies any contraindi-cations related to the patient’s current health status, recent conditions, exposures, or medications that can alter airway responsiveness, causing a false-positive or false-negative response.7This pretest evaluation is
not reported separately from the test since it is an integral part of the testing process. If a separate evaluation and management (E/M) service (ie, visit) occurs, the physician submits a claim for the E/M along with the appropriate procedure code. Append modifier 25 (separately identifiable evaluation and management service performed on the same day as a procedure or other service) to the E/M (eg, 99214-25) to alert the payer that the E/M exceeds the typical evaluation associated with testing, warranting additional payment. Please note that modifier 25 merely proposes additional payment but does not guarantee it. Examples of separately identifiable E/M services include a physician visit resulting in the decision to perform the prolonged exercise test for bronchospasm, or a visit to discuss the various forms of pharmacologic intervention related to the positive test results. Although standard coding guidelines permit use of the same International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) diagnosis code with each service,8it is
best to assign different ICD-9-CM codes when possible to clearly illustrate the separateness of each
service. As example, report 786.07 (wheezing) with the visit; and 493.81 (EIB) with the test.9
Supervision
The patient must be monitored both during and after exercise. Trained personnel should observe for signs of cardiopulmonary compromise: wheezing, chest pain, ECG changes, hypotension, oxygen de-saturation, or a decrease in coordination. A physician should be available to respond to any adverse events if necessary.1 Intervention could be as minimal as
administering a bronchodilator (94640) to relieve bronchoconstriction. Should this occur, reporting 94640 with EIB testing depends on the type of test provided and the testing location. 94640 is not reported with bronchoprovocation evaluations. It is considered a component of bronchoprovocation test-ing (94070) when provided to reverse the effects of test-induced bronchospasm. Similarly, any spiromet-ric measurements performed after bronchodilator administration to assess responsiveness (94060) are considered a component of 94070, and not reported separately. Bronchodilator administration (94640) is not considered a component of pulmonary stress testing and may be reported separately by the phy-sician in certain locations. Since 94640 is classified as a “technical” code in the Medicare Physician Fee Schedule (MPFS), having no associated “physician work” (identified by work relative value units in the MPFS), physician reporting of 94640 in facility-based laboratories or other facility-facility-based locations (eg, outpatient or inpatient hospitals, emergency departments, skilled nursing facilities) is not permit-ted. The facility itself must report “technical” codes to the insurer, when applicable. Therefore, physi-cians only report 94640 when performed in their private office.
Consistent with standards of care, federal regula-tions concerning diagnostic tests mandate different levels of physician supervision based on test type and complexity. The physician must be available by telephone or beeper (general supervision) during simple pulmonary stress testing (94620), whereas complex pulmonary stress testing (94621) and bron-chospasm provocation evaluations (94070) require physician presence in the suite (but not in the same room as the patient) during testing to intervene as necessary.10 If the indicated level of supervision is
not provided, the physician may not bill for the technical portion of the service (ie, the portion of the service that is carried out by the physician’s or facility’s technicians). Medicolegal risk increases as well.
Analysis
Assessing the response is a multistep process. For pulmonary stress testing (94620 or 94621), baseline spirometry (94010) is compared against serial post-test spirometric measurements, typically obtained 5, 10, 15, 20, and 30 min after cessation of exercise. Maintaining these timed testing intervals is required to avoid the refractory period phenomenon, the period in which little or no bronchospasm occurs (beginning 30 to 60 min after the test and lasting several hours). Some variations in posttesting can include earlier assessments when severe EIB is suspected. In bronchospasm provocation evaluation (94070), baseline spirometry (94010) is compared against posttest measurements 30 and 90 s after the administered dose of methacholine1; or 5, 10, and 15
min following hyperventilation of a gas mixture.5An
abnormal response to exercise testing is identified as aⱖ10% decrease from baseline FEV1, signifying a
positive EIB test. Some literature suggests using
ⱖ15% decrease in FEV1 as the threshold to
diag-nose EIB when testing occurs in the field.1A positive
methacholine inhalation challenge result is reported when the provocative concentration produces a 20% fall in FEV1at an interpolated dose ⱕ16 mg/mL.4
Reporting
Physician documentation must include the indica-tion for testing, the method utilized, obtained data, evidence of physician supervision, as well as physi-cian interpretation and report. These elements may be included in a comprehensive report or fragmented in the patient’s chart. As example, evidence of physician supervision can be accomplished through a simple statement (eg, supervised by Dr.*****), a “supervisor” signature line in the report, or retainment of physician schedules to facilitate documentation on audit. Failure to document any of these elements precludes claim submission, or prompts refunds for claims paid inap-propriately as a result of incomplete documentation.
Other factors play a key role in physician claim submission. One particularly significant factor of physician billing is the testing location. Most of the CPT codes involved in EIB testing have a profes-sional component as well as a technical component. No distinction between the professional and techni-cal component is made when physicians are billing for services performed in their private office: bill 94620 or 94621 for pulmonary stress testing; bill 94070, 95070 (reported for inhalation bronchial chal-lenge testing with methacholine), and J7674 (re-ported for each 1 mg of methacholine chloride administered as inhalation solution through a nebu-lizer) for methacholine challenge; 94070, 95071
(re-ported for inhalation bronchial challenge testing with gases) for EVH. Services performed in a facility-based setting (eg, outpatient hospital clinic or hospital-based laboratory) are handled differently: physi-cians may only report their “professional” services, and the facility reports the “technical” services. Most codes involved in EIB testing can be split into professional and technical components. The profes-sional components of EIB testing are identified by adding CPT modifier 26 (professional component) to the CPT code. The technical services are identified by adding modifier TC (technical component), un-less the procedure code is identified as “technical only” (ie, no [physician] work relative value units per the MPFS) such as 95070. Therefore, physician reporting of EIB testing in a facility setting is: 94620-26 or 94621-26 for pulmonary stress testing; 94070-26 for the bronchospasm provocation evalua-tion. Facility reporting of EIB testing represents the facility cost of staff to administer the testing, sup-plies, and materials: 94620-TC or 94621-TC for pulmonary stress testing; 94070-TC, 95070 or 95071, J7674 for the bronchospasm provocation evaluation (Table 1).9
Since spirometry (CPT 94010) is a required com-ponent of EIB testing, physicians should not report 94010 with pulmonary stress testing or the broncho-spasm provocation evaluation. The National Correct Coding Initiative (available at http://www.cms.hhs.gov/ NationalCorrectCodInitEd/) also considers 94010 a component procedure of 94070, 94620, and 94621, allowing the physician to only report the most com-prehensive service (94070, 94620 or 94621) on a given date. CPT Assistant provides an example of the exception to this rule: when an initial spirogram (94010) is performed with normal results, leading to the decision to perform further testing, 94010 can be reported separately.11,12Modifier 59 (distinct
proce-dural service) should be appended to 94010 in this circumstance, to distinguish the spirogram from the standard, inclusive spirometric component (eg,
Table 1—Code Selection Variables Office
Physician Codes
in a Facility Facility Codes Pulmonary stress
testing
94620 94620-26 94620-TC 94621 94621-26 94621-TC Methacholine
challenge
94070 94070-26 94070-TC
95070 95070
J7674 J7674
EVH 94070 94070-26 94070-TC
95071 95071
Bronchodilator administration
94640 94640
94010-59). Distinguishing the spirometry as a sep-arate procedure, when appropriate, may generate additional revenue from payers who recognize the medical necessity of the service and accept the modifier.
Medical Necessity
Reporting the correct CPT code(s) does not guar-antee payment for services. Medical necessity of the service(s) must be demonstrated for the payer to consider the service(s) reasonable and necessary, thus issuing payment. In an electronic world, the first-line defense for demonstrating medical neces-sity is the ICD-9-CM diagnosis code. Submitting a claim with a diagnosis code other than a payer-identified “acceptable” code renders the claim “med-ically unnecessary,” resulting in payment denial. Medically indicated diagnosis codes can vary by payer and mandated coverage may fall outside of clinically reasonable guidelines for testing. Most will accept a code for the corresponding test identified in Tables 2, 3,13 and some payers have expanded lists,
covering a broader range of diagnoses applicable to EIB testing (Table 4).14 Signs and symptoms are
equally as important as the definitive diagnosis. When testing confirms the presence of asthma, report the most appropriate asthma ICD-9-CM code (eg, 493.90) as the primary diagnosis on the claim form. Additional diagnosis representing patient symptoms (eg, shortness of breath 786.05; wheezing 786.07) may be reported, when applicable. If testing does not confirm the presence of asthma, do not report asthma on the claim form; only report the signs and symptoms that prompted the test.15
Do not be tempted to submit a “covered” diagno-sis code when none exists for the patient. Reporting
a diagnosis that the patient does not have, or that is not documented in the medical record can lead to payer misinterpretation of the physician’s intent. When tests are performed for clinically indicated rea-sons that are not “listed” by the payer, the physician must accept the nonpayment decision by the payer or bill the patient. Billing the patient may only occur when the insurer permits and an advance beneficiary notice is provided to the patient prior to testing with a detailed explanation of the potential coverage issues and associated costs. If accepted the patient signs the notice and the physician may bill the patient directly for services deemed “not medically necessary.” More information and instruction re-garding an advance beneficiary notice is available at http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp. Summary
EIB is becoming more prevalent as awareness is increasing and testing methods are expanding. Re-gardless of the testing method used, physicians are required to document and report their services accurately and appropriately. Consideration of the medical indication, test type, and testing location is often overlooked during the billing process, resulting in claim denial. Identifying the necessary informa-tion can assist physicians in reporting and receiving payment for services rendered.
References
1 National Asthma Education and Prevention Program, Na-tional Heart, Lung, and Blood Institute. Guidelines for the diagnosis and management of asthma: expert panel report 2. Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, 1997; publication 97-4051 2 Hansen-Flaschen J, Schotland H. New treatments for
exercise-induced asthma. N Engl J Med 1998; 339:192–193 3 Rundell KW, Anderson SD, Spiering BA, et al. Field exercise
vs laboratory eucapnic voluntary hyperventilation to identify airway hyperresponsiveness in elite cold weather athletes. Chest 2004; 125:909 –915
4 Eliasson AH, Phillips Y, Rajagopal KR, et al. Sensitivity and specificity of bronchial provocation testing. Chest 1992; 102: 347–355
5 Parsons JP, Mastronarde JG. Exercise-induced bronchocon-striction in athletes. Chest 2005; 128:3966 –3974
6 Koskela HO, Hyva¨rinen L, Brannan JD, et al. Responsiveness to three bronchial provocation tests in patients with asthma. Chest 2003; 124:2171–2177
7 Crapo RO, Casaburi R, Coates AL, et al. Guidelines for
Table 2—Typical Coverage Indications for CPT 94620, 94621
786.00-786.07 Respiratory abnormality unspecified – wheezing 786.09 Respiratory abnormality other
Table 3—Typical EIB Coverage Indications for CPT 94070
493.90 Asthma unspecified
493.91 Asthma unspecified type with status asthmaticus 518.89 Other diseases of lung not elsewhere classified 786.05 Shortness of breath
786.07 Wheezing
786.09 Respiratory abnormality other
786.2 Cough
Table 4 —Additional Payer-Specific Coverage Indications for EIB Testing
519.11 Acute bronchospasm
519.19 Other diseases of trachea and bronchus 786.7 Abnormal chest sounds
methacholine and exercise challenge testing-1999: this official statement of the American Thoracic Society was adopted by the ATS Board of Directors: July 1999. AM J Respir Crit Care Med 2000; 161:309 –329
8 American Medical Association. CPT 2008, current procedural terminology professional edition. Chicago, IL: American Medical Association, 2007; 457
9 Diamond E. Pulmonary function and exercise testing. In: Coding for chest medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 196 –203
10 Highmark Medicare Services. Part B reference manual: appen-dix L. Available at: http://www.highmarkmedicareservices.com/ partb/refman/appendix-l.html. Accessed January 30, 2008 11 American Medical Association. CPT assistant. July 2005; 15:7 12 American Medical Association. CPT assistant. January 1999; 9:1
13 Empire Medicare Services. Local coverage determination: pulmonary function testing. Available at: http://www. empiremedicare.com/nyorkpolicya/policy/l622_final.htm. Ac-cessed January 30, 2008
14 Centers for Medicare and Medicaid Services. Local coverage determination: pulmonary function studies. Available at: http://www. cms.hhs.gov/mcd/viewlcd.asp?lcd_id⫽25139&lcd_version⫽ 9&basket⫽lcd%3A25139%3A9%3APulmonary⫹Function⫹ Studies%3ACarrier%3ACahaba⫹Government⫹Benefit⫹ Administrators%C2%AE%7C%7C⫹LLC⫹%2800510%29%3A. Accessed May 30, 2008
15 Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 23, Section 101.1. Available at: http://www.cms.hhs.gov/manuals/downloads/ clm104c23.pdf. Accessed on May 29, 2008
