Question 1

How is a pulmonary function test billed?

Accepted Answer

Each test has its own code. Spirometry is 94010, and spirometry before and after a bronchodilator is 94060, which replaces 94010. Lung volumes are 94726 for the body box or 94727 for gas dilution, diffusing capacity is the add on code 94729, and the six minute walk test is 94618. The physician's interpretation is billed with modifier 26 when a facility owns the equipment, and a same-day office visit needs modifier 25.

Question 2

Can you bill 94010 with 94060, or a diffusing capacity on its own?

Accepted Answer

No to the first. 94060 contains spirometry and the bronchodilator, so 94010 and the nebulizer code 94640 are not reported with it, and the flow volume loop 94375 and maximum breathing capacity 94200 are also included. Diffusing capacity, 94729, is an add on code that CPT directs to be reported with a primary test such as 94010, 94060, 94726 or 94727, so we check that a primary test is on the claim before it is sent.

Question 3

How do you code critical care time?

Accepted Answer

Critical care is reported by the total time on the calendar date. 99291 covers the first 30 to 74 minutes, and 99292 covers each additional 30 minutes. Under the CPT rule 99292 is reported at 75 minutes, while Medicare requires the full 30 minutes beyond 74, so its first 99292 is at 104 minutes. Time spent on separately billed procedures is not counted, and under 30 minutes is reported with another E/M code.

Question 4

Can ventilator management be billed with critical care or a visit?

Accepted Answer

Not on the same day by the same clinician. CPT includes ventilator management in critical care, and Medicare's NCCI policy says ventilation management codes 94002 to 94004 and 94660 to 94662 are not separately reportable with E/M codes. We do not add these codes to a visit or a critical care claim.

Question 5

How are sleep studies billed, and what changes in 2027?

Accepted Answer

An in-lab study with sleep staging is 95810, and a study that adds CPAP or bilevel therapy is 95811, which is also the code for a split-night study. Home tests are 95800, 95801 and 95806, or G0398 to G0400 for Medicare. The CPT 2027 code set, which takes effect on January 1, 2027, replaces 95800, 95801 and 95806 with six new codes in three complexity levels, based on the number of channels recorded: 3 to 4, 5 to 10 and 11 or more. Each level has a technical and a professional code.

Question 6

What does Medicare require before it pays for CPAP?

Accepted Answer

Medicare covers CPAP for obstructive sleep apnea when the apnea hypopnea index is 15 or more, or 5 to 14 with documented symptoms such as daytime sleepiness or a condition such as high blood pressure, ischemic heart disease or a prior stroke. The diagnosis can come from an attended sleep lab study or from a type II, III or IV home sleep test. Coverage starts as a 12 week trial, and continued coverage needs a documented visit showing benefit and objective use data. We keep these items on file before the request is sent.

Question 7

How is a bronchoscopy with EBUS billed?

Accepted Answer

Endobronchial ultrasound sampling is 31652 for one or two lymph node stations and 31653 for three or more, and radial ultrasound for a peripheral lesion is the add on code 31654. A diagnostic bronchoscopy, 31622, is included in these codes at the same session. Transbronchial biopsy is 31628 for one lobe with 31632 for each additional lobe, and navigation is the add on code 31627. The procedure note must name the stations and lobes.

Question 8

How does a patient qualify for home oxygen under Medicare?

Accepted Answer

Group I coverage needs an arterial oxygen level of 55 mm Hg or lower, or a saturation of 88 percent or lower, at rest, during sleep or with exertion. Group II needs 56 to 59 mm Hg or a saturation of 89 percent plus a sign such as leg swelling from heart failure, pulmonary hypertension or a hematocrit above 56 percent. The test must be taken at the time of need by a clinician in person, so the date, reading and conditions have to be in the record.

Question 9

How are asthma biologics billed in the office?

Accepted Answer

Practices that buy and bill report the drug with its J code and the number of billing units in the descriptor, for example J2182 for mepolizumab per 1 mg, J0517 for benralizumab per 1 mg, J2356 for tezepelumab per 1 mg and J2357 for omalizumab per 5 mg, plus 96372 for the injection. Discarded drug from a single dose container is reported with modifier JW, and JZ when none is discarded. Many plans require approval first or send the drug through a pharmacy.

Question 10

How is lung cancer screening billed?

Accepted Answer

The low dose CT is 71271, and Medicare requires a counseling and shared decision making visit, billed as G0296, before the first scan. The patient must be 50 to 77, have no symptoms, have at least 20 pack years of smoking and either smoke now or have quit in the last 15 years, and the scan needs an order. The diagnosis is Z12.2 with a tobacco history code.

Question 11

Can you bill an E/M visit on the same day as a bronchoscopy, thoracentesis or spirometry?

Accepted Answer

Yes, when the visit is significant and separately identifiable, append modifier 25 to the E/M code. Medicare NCCI policy says the decision to perform a minor procedure is included in the procedure, and the bronchoscopy codes carry a zero day global period. A new problem or a full review of the lung disease supports the visit, while a routine pre-procedure check does not. AARC guidance also puts modifier 25 on the E/M when spirometry is done on a visit day. Modifier 57 is for the visit that decides on major surgery.

Question 12

How do you bill robotic or navigational bronchoscopy, and will payers cover it?

Accepted Answer

Robotic assistance has no CPT code of its own, so robotic and electromagnetic navigation are both reported with add on code 31627, computer-assisted image-guided navigation, alongside a primary bronchoscopy code such as 31628 for lung biopsy or 31629 for needle aspiration. Coverage is the harder part, because many plans cover navigation only for a peripheral nodule that needs tissue and cannot be reached by standard methods, or for fiducial placement. We check each plan's policy and prior authorization rule before the case is scheduled.

Question 13

Does Medicare pay for consultation codes like 99252 to 99255 when a pulmonologist is called to the hospital?

Accepted Answer

No. Medicare stopped paying consultation codes on January 1, 2010. The pulmonologist reports the first visit with initial hospital care codes 99221 to 99223 and later visits with 99231 to 99233, and the admitting physician adds modifier AI to the initial code. Office visits use the new or established patient codes. Some commercial plans still pay consultation codes and others do not, so our coders set the rule plan by plan.

Question 14

Does Medicare still pay for pulmonology telehealth visits in 2026 and 2027?

Accepted Answer

Yes. The Consolidated Appropriations Act, 2026, signed February 3, 2026, extends Medicare telehealth flexibilities through December 31, 2027. Patients can be seen at home with no rural limit, audio-only visits are allowed when clinically appropriate for services on the telehealth list, and any Medicare eligible practitioner can furnish them. A COPD, asthma or sleep apnea follow-up can qualify, but spirometry and sleep studies still need the patient on site. Without new law, the old limits return January 1, 2028.

Question 15

Can a pulmonologist bill chronic care management and remote monitoring for the same COPD patient?

Accepted Answer

Yes, in the same month with limits. CMS allows chronic care management and remote physiologic monitoring for the same patient in one month, but staff time counted toward one service cannot count toward another, and only one practitioner can bill CCM for a patient in a calendar month. A primary care practice already billing CCM therefore blocks yours. We confirm who holds the patient before enrolling, and keep separate time logs for each service.

Question 16

How do you bill outpatient pulmonary rehabilitation under Medicare?

Accepted Answer

Bill 94625 for a session without continuous oximetry and 94626 for one with it. These replaced HCPCS G0424 on January 1, 2022. Medicare covers moderate to very severe COPD, GOLD II to IV, and persistent post-COVID respiratory symptoms, with up to two one-hour sessions a day for 36 sessions and more when medically necessary, reported with modifier KX. A physician must sign the treatment plan every 30 days, and the sessions are billed from an office or hospital outpatient setting.

Question 17

How long does it take to get paid on a pulmonology claim?

Accepted Answer

A clean electronic Medicare claim can be paid as early as day 14, because of a 13 day payment floor, and paper claims wait longer. Interest starts after day 30 for clean claims not yet paid. Commercial plans set their own terms, and a claim that needs records or is denied takes longer. Medicare claims must be filed within one calendar year of the date of service, and a denial for late filing alone cannot be appealed.

Question 18

Which MIPS quality measures can a pulmonologist report in 2026?

Accepted Answer

The measures that fit pulmonology include 052 for COPD spirometry evaluation and long-acting inhaled bronchodilator therapy, 277 for sleep apnea severity assessment, 279 for sleep apnea therapy adherence and 398 for optimal asthma control. These are generally reported through a registry or an EHR feed rather than claims. The 2026 performance threshold is 75 points, and the largest penalty is 9 percent. We confirm each measure's current specification before the year starts.

Question 19

How much does pulmonology billing cost?

Accepted Answer

Most billing companies charge a percentage of the revenue they collect. Published vendor ranges commonly run from about 4 to 10 percent, and some offer flat monthly or per claim fees. The rate depends on claim volume, payer mix, how much work is included, such as coding, authorization and credentialing, and the state of your accounts receivable. We quote after reviewing your volume and payer mix.

Question 20

What is changing for pulmonology billing in 2026 and 2027?

Accepted Answer

As of October 2026, the new CPT 2027 code set takes effect on January 1, 2027 and replaces three home sleep test codes with six. In 2026, Medicare added remote monitoring codes 99445 for 2 to 15 days of data and 99470 for 10 minutes of management, and applied a 2.5 percent efficiency adjustment to the work value of procedure based services such as bronchoscopy, while time based services were exempt. CMS has proposed a lower conversion factor for 2027, about 32.84 dollars for most physicians, which is not final until the rule is published.

Question 21

Do you handle prior authorization for sleep studies and drugs?

Accepted Answer

Yes. Requirements vary by payer and by service, and many plans ask for approval before sleep studies, bronchial valves and thermoplasty, and asthma biologics. For plans covered by the federal prior authorization rule (CMS-0057-F), payers must decide within 72 hours for urgent requests and 7 calendar days for standard ones. We request approval when the order is placed and track it to a decision.

Question 22

What do you need from us to get started?

Accepted Answer

EHR or practice management access, your payer list and fee schedules, your recent denial reports, and a list of physicians and sites. We usually begin with an audit of breathing test, critical care and sleep claims, because that is where the fastest gains are.

Question 23

What should a pulmonology practice look for in a billing company?

Accepted Answer

Look for coders who understand how breathing tests overlap, how critical care time is counted by payer, how sleep studies and CPAP coverage work, and how bronchoscopy services are bundled. Ask how authorization for sleep testing and biologics is handled and what reports you receive. DrCareMSO builds each pulmonology claim from the tests and steps actually performed.

Question 24

How do pulmonology billing services handle COPD and asthma patients?

Accepted Answer

COPD and asthma care mixes office visits, breathing tests, inhalers and biologic drugs, home oxygen documentation and monthly care management. We match each diagnosis to coverage policy, keep included tests off the claim, track drug units and waste, and log chronic care and remote monitoring time so those monthly services are billed when their counts are met.

Question 25

Do you bill for sleep medicine, including home sleep tests and CPAP?

Accepted Answer

Yes. We bill in-lab and home sleep studies, sleep clinic visits and the follow up CPAP documentation Medicare requires. We confirm the test type, the apnea index and the follow up visit date, and we track the January 1, 2027 sleep testing changes so your claims are ready for them.

Question 26

How do you handle critical care billing for intensivists and pulmonologists?

Accepted Answer

We total critical care time for each calendar date, apply the right payer's time rule, leave out services that are included, and bill procedures such as intubation and chest tubes on their own with their time excluded. Shared visits with nurse practitioners and physician assistants are assigned to the clinician who did more than half of the time.

Question 27

How do you reduce denials for pulmonology claims?

Accepted Answer

We verify coverage and authorization before tests and scopes, build each claim from what was performed, apply bundling edits before submission, and correct rejections the same week. Monthly reports group the denials that remain by cause so we can fix the source.

Question 28

How do I choose a pulmonology billing company?

Accepted Answer

Look for coders trained in pulmonology claims, a plan for authorizations before the case or study, denial follow-up that continues until the claim is paid or appealed, and a monthly report you can read without a billing background. Ask who owns the payer deposits (they should go to your account) and ask to see a sample report before you sign.

Question 29

Is outsourcing billing a good fit for a small pulmonology practice?

Accepted Answer

Often yes. A small practice carries the same payer rules as a large one, but with fewer staff to track breathing tests, sleep studies, bronchoscopy and critical care. Outsourcing replaces a part time billing hire with a team that works the claims every day. The right choice depends on your volume and how much time your staff spend on denials today, and we can look at your numbers with you on the first call.

Question 30

What reports will I receive from a pulmonology billing company?

Accepted Answer

We send a monthly report that shows what was billed and paid, what is still open and why denials happened, grouped by cause so the source can be fixed. You can also ask for the payer mix and the oldest unpaid claims. Report details are agreed when you start, so you only get what you will use.

Pulmonology medical billing, from spirometry to the ICU

What does a pulmonology billing company do?

Where pulmonology claims lose money

Breathing tests that overlap

Critical care time counted the payer's way

Sleep testing rules that keep changing

Bronchoscopy billed by what was done

What we bill in every pulmonology claim

Breathing tests

Bronchoscopy and EBUS

Pleural procedures

Critical care and ventilator management

Sleep medicine

Drugs, oxygen and screening

Chronic care and remote monitoring

Monthly and nightly counts that decide the claim

Build a lung function claim, test by test

How we run pulmonology RCM

Verify coverage and approval rules

Capture the service at the source

Code from what was done

Apply the bundling edits

Submit, work denials and fix the cause

Why pulmonology practices choose DrCareMSO

Certified coders for pulmonology claims

Approvals before the case is scheduled

Every denial worked to payment

A monthly report in plain language

One pulmonology group, three leaks, fixed

Pulmonology billing questions

Start with an audit of your breathing test and critical care claims

Schedule Your Free Demo

Dr. Care AI

Welcome! 👋