Specialty rules are applied to the practice's payers, documentation, and schedule during the engagement.
Where the billing gets difficult
Spirometry without acceptable effort
Payers and code definitions expect a valid study. A printout that the physician did not accept is not automatically a billable test.
Sleep study component confusion
The practice may interpret a study performed by a lab. Billing the technical component as well double-bills the lab's work.
Oxygen and device requests mixed into the visit
Qualifying studies and prescriptions are documentation tasks. They are not extra visit levels unless the work meets an E/M definition.
Coding considerations
Pulmonary function components
Spirometry, lung volumes, and diffusion have distinct codes. Bundling habits in the fee schedule are checked against what was performed.
Professional interpretation
Modifier 26 is used when the practice reads a study it did not technically perform.
Procedures
Bronchoscopy and related interventions are coded from the procedure report, including whether a biopsy was done.
Documentation the claim needs
- Test quality and physician interpretation for pulmonary function
- Ownership of sleep-study technical components
- Procedure extent and specimens
- Indication that supports the test under the payer policy being used
Reimbursement complexity
Pulmonary function revenue is lost in incomplete studies and in global billing of tests performed elsewhere. Sleep interpretations are a smaller, easy-to-miss queue if the report arrives from an outside lab. Procedure claims need authorization more often than a follow-up visit for asthma or COPD. Patient statements should not include a technical component the practice did not perform and the payer correctly denied.
Proposed approach
01
Define a billable study
The practice states what makes a spirometry acceptable. Others are not billed as complete.
02
Map outside studies
Sleep and imaging reads are flagged as professional-only unless the practice owns the equipment.
03
Code procedures from the report
Bronchoscopy interventions are taken from the report, not from the scheduled procedure name.
Workflow checks
- PFT quality check
- Professional-component flag for outside studies
- Procedure auth match
- Interpretation signature queue
Questions
Do you bill durable medical equipment?
Only when the practice is set up as a supplier for that item and the engagement includes it. A prescription for oxygen is not itself a DME claim.
Are all spirometry tests billable?
No. A study the physician does not accept as valid should not be billed as a complete test. The practice's definition is written down.