Specialty
Pulmonology billing services
Pulmonology billing services get a lung practice paid for testing, treatment and screening that payers price in small, rule-bound pieces: spirometry with the bronchodilator already inside it, inhalation treatments counted once per episode of care, pulmonary rehabilitation sessions built up from minutes, and lung cancer screening that turns on age, pack-years and a tobacco diagnosis on the claim line.
See where claims are getting stuck. No patient data needed.
Remitwright gives pulmonology practices a dedicated biller who reads the test report and the session log before each claim goes out, keeps visits apart from the testing they sit beside, and works every denial back to the rule that caused it.
Pulmonology billing is one of Remitwright's specialty billing services, each set out with its own code families, denial reasons and payer rules.
Last reviewed by the Remitwright billing team. Editorial policy
- 31622
- 32554-32557
- 94002-94004
Denials
Why pulmonology claims get denied
The reasons that come up most on pulmonology remittances, with the usual cause and the fix. Code explanations are our own; the official list is maintained by X12.
| Code | Reason | Usual cause | The fix |
|---|---|---|---|
| CO-97 | Bronchodilator billed as a treatment | 94640 billed for the bronchodilator given inside 94060, or spirometry billed before and after a treatment for an obstructed airway | Testing days and treatment days coded from the purpose in the note, with the drug billed on its own line in either case |
| CO-167 | Screening line with no tobacco diagnosis | G0296 or 71271 sent without Z87.891 or one of the F17.21 nicotine dependence codes the claims manual lists for lung cancer screening | Smoking history, pack-years and quit date read from the visit note and coded before the line is released |
| CO-96 | Rehab billed from a setting Medicare will not cover | Pulmonary rehabilitation on a professional claim with a place of service other than 11 for the office or 22 for an outpatient hospital | Place of service set to 11 or 22 from where the sessions actually run, and rehab in any other setting not billed as covered |
| CO-119 | More than two rehab sessions in one day | Three or more units of 94625 or 94626 on one date, or a second unit when the day's minutes did not reach 91 | Minutes totaled for the date before units are set: 31 to 90 minutes is one session, 91 or more is two, and two is the ceiling |
| CO-151 | Rehab past session 36 without KX | Session 37 or later billed the same way as the first 36, with no KX and no notes showing why the course should continue | A running session count per patient, with the extended course reviewed and documented before session 37 is billed |
| CO-50 | Patient outside the rehab conditions | Rehab billed for a patient whose record shows neither COPD staged GOLD II to IV nor respiratory symptoms lasting four weeks or more after COVID-19 | The qualifying condition and the referral from the treating physician confirmed when the patient is enrolled |
Codes
Common pulmonology codes and modifiers
Code families by number with our own one-line explanations. CPT descriptors belong to the AMA and are not reproduced here.
| Codes | What the family covers |
|---|---|
| 31622, 31635 | Diagnostic bronchoscopy, and surgical bronchoscopy such as removing a foreign body, which absorbs the diagnostic look when both happen at one session. Examining the nose, throat and larynx on the way in is part of the bronchoscopy. |
| 32554-32557 | Thoracentesis and pleural drainage. The chest film taken afterwards to confirm placement or check for a complication is part of the procedure and is not billed on its own line. |
| 94002-94004, 94660 | Ventilation management, including CPAP set-up and management. When a visit and a ventilation management code are billed for the same patient and day, Medicare pays only the visit. |
| 94010, 94060, 94070 | Spirometry alone, spirometry repeated after a bronchodilator, and bronchospasm provocation. One unit covers every effort the test needs, and a flow volume loop is another way of reading the same session, so it is not a line of its own. |
| 94618, 94621 | A pulmonary stress test and the full cardiopulmonary exercise test. The exercise test absorbs its parts, from oximetry and ECG monitoring to gas exchange and the spirometry before and after, and the pulmonary stress test is not billed with it at the same encounter. |
| 94625, 94626 | Pulmonary rehabilitation sessions since January 2022, split by whether oxygen saturation is watched continuously. G0424 carried the same service before then. A session needs at least 31 minutes in the day, and minutes from shorter periods on one date are added together. |
| 94640, 94644, 94645, 94664 | Nebulizer or inhaler treatment given for an obstructed airway or to bring up a sputum sample, billed once per episode of care however many treatments run; continuous treatment by the hour once it passes an hour; and teaching or checking the patient's own device, which folds into 94640 when the same device is used at that encounter. |
| G0296, 71271 | Lung cancer screening: the counseling and shared decision making visit held before the first scan, and the low dose CT itself, which took over from G0297 at the end of 2020. Medicare applies no deductible or coinsurance to either line. |
Modifiers that matter
- 25
- A significant visit for a problem separate from the test or treatment given that day. The brief history and exam a physician does to run the test are part of the test and do not support a visit.
- 76
- A second inhalation treatment on the same date of service, used only when the patient left and came back for a new episode of care.
- KX
- Pulmonary rehabilitation sessions after the 36th, once the record supports continuing. Medicare denies those sessions without it, and since 2022 the same applies to sessions beyond the 72nd.
- GA and GZ
- GA when a signed advance beneficiary notice is on file for a rehab service Medicare may deny, which moves the liability to the patient; GZ when there is no signed notice, which leaves it with the practice.
Pulmonary rehabilitation billing, minute by minute
Medicare pays pulmonary rehabilitation by the session, but a session is defined by minutes. Under 31 minutes in a day bills nothing. From 31 to 90 minutes is one unit of 94625 or 94626, and 91 minutes or more is two, which is the most a patient can have on one date. A patient who does 25 minutes in a morning class and 40 in the afternoon has 65 minutes, so the day is one session, not two short ones.
The count runs across the course as well as the day. The 37th session onward needs modifier KX and notes that support continuing, and the extended course has to be medically necessary for that patient. Each line also has to show where the session took place: place of service 11 for a physician office program and 22 for an outpatient hospital program, with any other code denied. Your biller keeps the minute log, the session count and the 30-day plan signatures together, which is what a Medicare billing review of a rehab program asks to see.4
Lung cancer screening claims: the visit, the scan and the diagnosis
Screening is two services. G0296 is the counseling and shared decision making visit that confirms eligibility, uses a decision aid, and covers adherence, other conditions and smoking cessation or staying quit. 71271 is the low dose CT. Medicare covers the visit before the first scan and the scan once a year, with at least 11 full months between screenings.
Both lines are checked against age, 50 to 77, and against the diagnosis on the line, which has to be Z87.891 for a history of tobacco use or one of the cigarette nicotine dependence codes the claims manual lists. NCD 210.14 limits the benefit to people with no signs or symptoms of lung cancer, so a scan ordered to work up a symptom is not a screening claim and does not belong on 71271 or behind a G0296 visit.6
Payers
Payer notes
- Medicare94060 already includes giving the bronchodilator, so 94640 is not billed for that dose, though the drug itself can be. 94640 is reported once per episode of care, even an episode that crosses midnight; a separate episode on the same date takes modifier 76, and treatment running past an hour moves to 94644 and 94645.1
- MedicareVentilation management codes 94002-94004 and 94660 are not paid alongside a visit code; if both are billed, only the visit is payable. A cardiopulmonary exercise test includes its component tests, and a cardiac or pulmonary stress test at the same encounter is not billed with it.1
- MedicareFiberoptic bronchoscopy includes the look at the nasal cavity, pharynx and larynx, and a diagnostic bronchoscopy is not billed with a surgical one from the same session. After thoracentesis, pleural drainage or a chest tube, the confirming chest X-ray is not billed.2
- MedicarePulmonary rehabilitation is covered for moderate to very severe COPD, GOLD II, III or IV, on referral from the physician treating the respiratory disease, and since January 1, 2022 for confirmed or suspected COVID-19 with respiratory symptoms lasting at least four weeks. The limit is two one-hour sessions a day and 36 sessions over up to 36 weeks, with 36 more if the MAC approves, and a physician signs the treatment plan every 30 days.3
- MedicareRehab is billed on 94625 or 94626 from 2022. One session needs at least 31 minutes in the day and two need at least 91. Professional claims must show place of service 11 or 22, and institutional claims type of bill 13X or 85X with revenue code 0948.4
- MedicareLow dose CT screening is covered for people aged 50 to 77 with no signs or symptoms of lung cancer, at least 20 pack-years of smoking, who smoke now or quit within the last 15 years, after a counseling and shared decision making visit before the first scan that uses one or more decision aids.5
- MedicareThe claims manual allows one 71271 a year, with at least 11 full months since the last screening, rejects G0296 and 71271 outside ages 50 to 77, and requires Z87.891 or a listed F17.21 code on each line. Neither code carries a deductible or coinsurance.6
Authorizations
Original Medicare does not ask for prior authorization on office spirometry, rehab or lung cancer screening, but it sets gates that work the same way: a GOLD stage or post-COVID history and a referral for rehab, age, pack-years and a counseling visit for screening, and a documented review once a patient passes 36 rehab sessions. Commercial and Medicare Advantage plans keep their own authorization lists, which can take in procedures, imaging and injected drugs, and each plan changes its list on its own schedule. Your biller keeps that list by payer and code, requests authorization when the service is ordered, and carries the number to the claim.
Documentation traps
- A spirometry or exercise test report with tracings and values but no signed interpretation, which leaves the professional work undefended
- The bronchodilator recorded only as a nursing note with no drug, dose or route, so the drug line cannot be billed
- Rehab attendance logged as present or absent instead of minutes, which gives no way to count sessions for the day
- A shared decision making note that leaves out the decision aid, the pack-year count or the quit date
- A rehab treatment plan signed at enrollment and not again every 30 days
- A visit note on a testing day that repeats the test's own history instead of the separate problem the 25 modifier claims
What a specialist checks
Specialist or generalist for pulmonology billing?
A generalist biller can enter a pulmonology claim. Whether it pays turns on three things specific to pulmonology billing, and a specialty-aware biller checks each one.
Code families
Each family billed with what the chart has to show for it.
- 31622, 31635
- 32554-32557
- 94002-94004, 94660
Modifiers
Applied only where the note supports them, line by line.
- 25
- 76
- KX
If you are moving from another billing company or an in-house biller, switching billing companies follows a plan: the old and new processes run side by side until the new one is proven, and every login and every pulmonology claim stays in your name.
What we handle
What we handle for pulmonology practices
- Medical codingCPT, ICD-10 and modifiers assigned correctly
- Charge entryEvery encounter captured, nothing left unbilled
- Claim submissionScrubbed, submitted and tracked to acceptance
- Medicare billingPart B claims, MSP, ABNs and appeals
- Denial managementEvery denial read, worked and appealed
- A/R follow-upUnpaid claims chased before filing limits
A dedicated biller with named cover, working inside your system and reporting to you on one written page. How it works sets out the five stages.
Worked example: the rehab patient who reached session 37
A pulmonology practice runs an office rehab program. A patient with COPD staged GOLD III reaches session 37 late in the course, and the charge template sends 94626 the same way it sent the first 36. Medicare denies the next three sessions for frequency.
The biller pulls the session count, finds the treatment plan re-signed every 30 days and progress notes that support continuing, and asks the physician to confirm and document that the extended course is medically necessary. The denied lines go back with KX, and the template now stops at session 37 for every patient until that review is on file.
Software
Systems pulmonology practices usually run
Your biller works inside your system as a user you create. All the systems we work in.
Questions
Questions about pulmonology billing
Can we bill 94640 on the same day as 94060?
How many pulmonary rehab sessions does Medicare cover?
Who qualifies for Medicare lung cancer screening?
Can a pulmonologist bill a visit on the same day as pulmonary function tests?
Is a cardiopulmonary exercise test billed with its parts?
Do we bill the chest X-ray after a thoracentesis?
What does a pulmonology practice provide so billing can start?
Next step
See where your pulmonology claims are getting stuck.
Three quick questions. No patient data. A billing specialist reads every request and replies in writing.
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- No patient data, no software to buy
- A written reply from a biller, not a sales deck
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- A billing specialist reads your answers and replies by email.
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While you wait: see the sample weekly report or read how switching works. You can also download the sample weekly report (PDF).