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Section: Diagnostic Medical
Number: M-19
Topic: Pulmonary Function Studies
Effective Date: November 3, 2008
Issued Date: November 3, 2008
Date Last Reviewed: 10/2008

General Policy Guidelines

Indications and Limitations of Coverage

Pulmonary Function Studies

Claims reporting only "Pulmonary function studies" will be processed under procedure code 94010. When a physician reports a "complete spirometry" (code 94010) and itemized charges for one or more of the following procedures, the charges will be combined and processed under code 94010. No additional allowance will be made unless they are performed independently.

  1. Maximal Expiratory Flow Rate (MEFR) also known as Forced Expiratory
    Flow (FEF 200-1200), 94799
  2. Maximal Mid Expiratory Flow Rate (MMEFR) also known as Forced Expiratory FEF 25-75), 94150.
  3. Maximal breathing capacity, maximal voluntary ventilation, 94200
  4. Vital capacity, total, 94150
  5. Vital capacity screening tests: Total capacity with timed forced expiratory volume (state duration), and peak flow rate, 94150.
  6. Various Forced Expiratory Volume studies such as FEV1, FEV1%, FEV2, or FEV3, 94799
  7. Respiratory flow volume loop, 94375

Peak Expiratory Flow Rate (PEFR) using a Wright Peak Flow Meter is frequently done as a separate procedure apart from complete spirometry. If reported, payment will be made under procedure code S8110.

Claims reporting bronchodilation responsiveness will be processed under procedure code 94060. A complete spirometry is included in this procedure; therefore, if an itemized charge is reported for spirometry when performed in conjunction with bronchodilation responsiveness, the charges will be combined and processed under code 94060.

Patient Initiated Spirometry

Patient initiated spirometry will be reimbursed only when indicated for the following conditions:

  • Following lung transplantation to monitor for problems such as rejection (996.84, V42.6), infection, or bronchiolitis obliterans (491.8); or
  • For patients diagnosed with severe asthma (493.00-493.02, 493.10-493.12, 493.20-493.22, 493.90-493.92) who meet all of the following criteria:
    1. Severe asthma, with both: dyspnea at rest, and FEV1<40% predicted after bronchodilator administration.*
    2. Two hospitalizations or three emergency room visits in the past 90 days for poorly controlled asthma or intercurrent respiratory infections.
    3. Evidence of end-stage disease by any one of the following: hypoxemia at rest (pO2<55mmHg or O2sat<88%); hypercapnia (pCO2 >50mmHg); secondary polycythemia (HgB>18g/dl); or cor pulmonale/right heart failure determined by EKG, echocardiography, or cardiac cath.*

    *These measurements should be determined more than 14 days before or after a hospitalization or emergency room visit, to ensure that they are stable baseline measurements and not markers of acute illness.

Any patient utilizing this service must be mentally and physically capable of performing this test independently.

For asthmatic patients utilizing this service, the medical record must clearly delineate the above criteria.

The following codes are used to report patient initiated spirometry:

  • Code 94014 describes the global service (i.e., both the professional and technical components of the service).

  • Code 94015 describes only the technical component of the service, including recording, hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic recalibration.

  • Code 94016 describes only the physician (professional) component of the service.

Description

Pulmonary Function Studies

Pulmonary function studies is a categorical term for diagnostic tests performed to determine how the lungs are functioning.

Patient Initiated Spirometry

Transtelephonic spirometry, also known as patient initiated spirometry, is a method of obtaining ongoing spirometric analysis of lung function. Transtelephonic spirometry requires the patient to perform the spirometry based on time intervals or criteria predetermined by the physician. The results are stored in a small computer that is part of the spirometer. The data is downloaded via modem from the spirometer's computer to another computer. The data is then trended and analyzed by the provider to identify problems. This service includes all measurements, transmissions and interpretations over a 30-day period.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

940109401494015940169406094150
942009437594799S8110  

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

How Accurate is Spirometry at Predicting Restrictive Pulmonary Impairment?, Chest, Vol. 115, No. 3, March 1999

Monitoring Progress After Lung Transplantation From Home-Patient Adherence, JMed Eng Tech, Vol. 20, No. 6, November - December 1996

The Effectiveness of an Interactive Electronic Lung Function Monitoring System in the Total Management of Refractory Asthma, Disease Management Health Outcomes, Vol. 3, No. 2, February 1998

Staging of Bronchiolitis Obliterans Syndrome Using Home Spirometry, Chest, Vol. 116, No. 1, July 1999

New Developments in the Home Monitoring of Asthma, The Internet Journal of Asthma, Allergy and Immunology, www.ispub.com/journals/IJAAI, Vol. 11, No. 1

Internet-Based Home Asthma Telemonitoring, Chest, Vol. 117, 2000

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Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.



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