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.

Modifier 59 may be reported with a respiratory flow volume loop test to identify it as distinct or independent from a complete spirometry performed on the same day. When modifier 59 is reported, the patient’s records must clearly document that a respiratory flow volume loop test was done in addition to a complete spirometry.

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, infection, or bronchiolitis obliterans; or
• For patients diagnosed with severe asthma 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.

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.

Patient initiated spirometry performed for all other conditions is considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

NOTE:

A spirometer (A9284, E0487) is included in the professional service and, therefore, is not eligible for separate reimbursement. A participating, preferred, or network provider cannot bill the member for the denied 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.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program.

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