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Pulmonary Procedures and Evaluation & Management (E/M) Services performed on the same day


Recovery Auditors have identified overpayments associated with Evaluation and Management (E/M) Services (Common Procedure Terminology (CPT) 99211-99213) for Pulmonary Diagnostic Procedures. These overpayments occurred due to claims billed without Modifier 25 on the same date of service as a pulmonary diagnostic, therapeutic, or monitoring procedure (94010-94799).  You and your staff should be familiar with the definitions of CPT 99211-99213 and the correct use of modifier 25, when providing pulmonary diagnostic, therapeutic, or monitoring procedures.

Billing Considerations

If a physician in attendance for a pulmonary function study obtains a history and performs a physical examination related to the pulmonary function testing, separate reporting of an E/M service is not appropriate.

If a significant, separately identifiable E/M service is performed unrelated to the performance of the pulmonary function test, an E/M service may be reported with Modifier 25. 

If the E/M was not separately identifiable, then the E/M service should not be billed.

Case Studies

1.  A provider billed CPT code 94010 (Breathing capacity test) with no modifier for date of service September 19, 2011. The same provider also billed CPT code 99213 for the same patient on the same date of service without a modifier. CPT code 99213 should not be billed if the E/M service was related to the code 94010. Separate reporting of an E/M service is not appropriate because a health care professional in attendance for a pulmonary function study obtains a history and performs a physical examination related to the pulmonary function testing. If the E/M service was not related to the 94010, then 99213 can be billed with modifier 25.

2.  A provider billed CPT code 94060 (Evaluation of Wheezing) with no modifier for date of service February 12, 2011. The same provider also billed CPT code 99212 for the same patient on the same date of service without a modifier. CPT code 99212 should not be billed if the E/M service was related to the code 94060. Separate reporting of an E/M service is not appropriate because a physician in attendance for a pulmonary function study obtains a history and performs a physical examination related to the pulmonary function testing. If the E/M service was not related to the 94060, then 99211 can be billed with modifier 25.


Source: MLN Matters®   Number: SE1315

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