Pulmonology practices handle a wide mix of services, diagnostic testing, complex procedures, and chronic disease management. Each has specific coding requirements, and the margin for error is thin when payers are scrutinizing respiratory care more closely than they were even two years ago. The financial stakes here are real: a recurring gap in this area adds up to lost or delayed revenue every month.
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PFTs are the diagnostic backbone of pulmonology. The key codes:
A full PFT panel can legitimately include several of these codes. But billing all of them when only some were performed is overbilling. Each test must be documented as having been performed, interpreted, and clinically indicated on that date.
Bronchoscopy has a range of codes depending on what's done during the procedure. The base bronchoscopy code (31622) is rarely billed alone; it typically includes additional procedures:
The correct approach: bill the appropriate diagnostic bronchoscopy code(s) for what you actually did. Don't add procedure codes to inflate the claim. And don't bill the base code when you performed additional procedures that have their own codes.
Pulmonologists who supervise or interpret sleep studies bill through a set of Type I–IV codes. Type I (attended, in-lab full polysomnography) uses 95810 for the diagnostic study and 95811 if CPAP titration is performed during the same night. Type III (home sleep apnea testing) uses 95806.
Prior authorization is almost universally required for sleep studies. Submitting without auth is a predictable denial. And the indication documentation has to match payer criteria, typically an ESS score, documented symptoms, and a clinical note that reflects the pre-test evaluation.
ICU-level ventilator management uses daily critical care codes (99291, 99292) when the pulmonologist is providing critical care. The distinction: critical care billing requires that the physician is providing direct, hands-on management of a life-threatening condition, not just reviewing vent settings from a standing order.
A lot of pulmonologists underbill inpatient time by defaulting to standard subsequent hospital care codes when they're actually providing critical care. If the patient is on mechanical ventilation and you're managing their care actively, document and bill critical care.
Pulmonary rehabilitation (G0424) is a separately billable service for patients with COPD meeting specific criteria. It's often underused in pulmonology practices even when patients clearly qualify. Medicare covers up to 36 sessions with a physician-prescribed program and documentation of medical necessity.
Chronic care management codes (CCM) apply to COPD patients with two or more chronic conditions. PCM codes apply specifically to COPD as the principal condition being managed. These are real revenue that most pulmonology practices are leaving uncaptured.
EBUS procedures for lymph node staging have their own codes (31652, 31653). These are add-ons to the bronchoscopy code (31629 for EBUS guidance without biopsy, 31652/31653 for with biopsy). The documentation needs to reflect the EBUS component specifically, stations sampled, size of nodes, technique used. EBUS billing without this level of detail is a denial waiting to happen.
See how Rcmaxis handles the full scope of Pulmonology billing on our Pulmonology billing services page.
Pulmonology reviews focus on three areas. Pulmonary function tests are checked for medical necessity and for whether the pre- and post-bronchodilator studies were both actually performed. Bronchoscopy claims are checked for the add-on procedures billed against the operative note. And critical care is checked for the documented time and direct management that the code requires, particularly when a pulmonologist bills daily ventilator management. Because contractors can extrapolate a sample error rate across the full lookback period, a documentation gap that looks minor on paper can become a much larger repayment demand.
Sleep studies add another layer, because the study type determines the code and the interpreter's role has to be documented. Contractors can look back three years, and because pulmonology practices repeat the same tests, a documentation gap on one test type carries across a large number of patients. Match a sample of PFT and bronchoscopy claims to their reports each quarter.
A pulmonary function test claim needs an order with a clear reason, a technically acceptable test, and an interpretation. Make sure the order names the symptom or diagnosis that prompted the test, and that the report shows the values, the comparison to predicted, and the interpreting physician's signature. If the pre- and post-bronchodilator study was done, the record should show the drug, the dose, and the repeat measurements.
Check your equipment and staff credentials, too. Payers can ask for proof that testing met quality standards, and a missing calibration record is an unnecessary reason to question a claim. Keep a simple log of calibration dates and technician training.
Bronchoscopy claims often list several add-on services, and each one needs to be in the operative note. Before billing, read the note line by line against the codes: brushings, lavage, biopsies, and any guidance or navigation. If a service was planned but not done, it doesn't go on the claim. If it was done but not described, add a documented addendum rather than assuming the claim will pass.
For EBUS, note the stations sampled and the number of samples, since the codes depend on them. A short structured template for the operative note prompts the physician for each element and makes the coder's job faster.
Pulmonology practices manage COPD, asthma, and other chronic conditions over years. Care management, pulmonary rehab referrals, and remote monitoring can all support that care when patients qualify. Review your panel once a quarter for patients who meet the criteria and haven't been offered these services, and give a staff member ownership of the outreach.
Once a quarter, list your ten highest-volume codes and check the denial rate and average payment for each. Compare the payment to your contracts. If a code is underpaid or denied often, look at the notes and the claim for a cause, and fix the pattern instead of appealing each claim.
Spirometry is 94010, and spirometry before and after a bronchodilator is 94060, according to the article's key codes. Document both parts of the pre and post study, since 94060 depends on the bronchodilator response.
Only when the physician is providing direct, hands-on management of a critically ill patient. The article separates that from routine ventilator management, and critical care codes 99291 and 99292 need time documented.
Pulmonary rehabilitation (G0424) is separately billable for COPD patients who meet specific criteria, and the article notes Medicare covers up to 36 sessions. Many practices underuse it even when patients clearly qualify.
For pulmonary rehab (94625 and 94626), see our cardiac and pulmonary rehab billing guide.
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