Pulmonology billing services
Office visits, pulmonary function testing, bronchoscopy, ICU critical care and sleep medicine each bill differently. We handle all of them for your pulmonary group.
Why pulmonology billing takes specialty knowledge
Pulmonology groups often work across the office, the hospital and the sleep lab. In the office, pulmonary function tests are built from several component codes that must be combined correctly. In the hospital, critical care is billed by time with different rules for Medicare and CPT. Bronchoscopy procedures have bundling relationships, and sleep studies need prior authorization and specific equipment rules for CPAP coverage.
SFA Solutions codes each setting with the details payers check. We bill global, professional or technical PFT components depending on where testing is done, apply Medicare's critical care time thresholds and code bronchoscopy and EBUS by what was actually sampled. We work inside your EHR and aim to submit most clean claims within 24 hours of final review, after checking each claim against applicable payer rules.
Common codes we work with in pulmonology
| Code | Description |
|---|---|
| 94060 | Spirometry with bronchodilator responsiveness, pre and post |
| 94726 | Plethysmography for lung volumes and airway resistance |
| 94729 | Diffusing capacity (DLCO), add-on |
| 94618 | Pulmonary stress testing (for example, 6-minute walk test) |
| 31622 | Bronchoscopy, diagnostic, with cell washing when performed |
| 31652 | Bronchoscopy with endobronchial ultrasound guided sampling, 1 or 2 mediastinal or hilar lymph node stations or structures |
| 99291 | Critical care, evaluation and management, first 30 to 74 minutes |
| 95810 | Polysomnography, age 6 or older, 4 or more additional parameters, attended by a technologist |
CPT is a registered trademark of the American Medical Association. Payer rules vary; we check each payer's current policy.
Where pulmonology practices lose revenue
PFT component coding
Spirometry (94010), pre and post bronchodilator spirometry (94060), plethysmography (94726) and diffusing capacity (94729, an add-on) are billed together when all are performed. 94010 is bundled into 94060. When testing is done in a hospital lab, the pulmonologist bills only the interpretation with modifier 26.
Critical care time rules
99291 covers the first 30 to 74 minutes of critical care and 99292 each additional 30 minutes. Medicare requires 104 total minutes before 99292 can be billed, while CPT allows it at 75 minutes. Split or shared visits between physicians and APPs need modifier FS, and time from different providers cannot be double counted.
Bronchoscopy and EBUS
Diagnostic bronchoscopy (31622) is included in surgical bronchoscopy codes. EBUS is coded by the number of stations sampled: 31652 for one or two stations and 31653 for three or more. Transbronchial lung biopsy (31628) and its add-on for additional lobes are coded per lobe.
Sleep studies and CPAP
In-lab polysomnography (95810, 95811) usually needs prior authorization, and many payers require a home sleep test first. Medicare covers CPAP after a qualifying study and requires adherence of at least 4 hours a night on 70% of nights in a 30-day period during the first 3 months.
What else affects pulmonology revenue
A/R challenges in pulmonology
Pulmonology A/R is spread across office testing, hospital rounds and sleep studies, and each setting has its own timelines. Hospital critical care and consult charges are often delayed by late charge capture or missing facesheets from the inpatient team. Sleep study and CPAP-related denials tend to age because the appeal needs clinical records, so they should be worked early.
Credentialing considerations
Pulmonologists need privileges and payer enrollment at each hospital where they round and each facility where they perform bronchoscopy. A freestanding sleep lab that bills the technical component usually enrolls with Medicare as an independent diagnostic testing facility, with its own supervision rules. Many commercial plans also require sleep facilities to hold accreditation, often from the AASM.
Payer considerations
Many commercial and Medicare Advantage plans manage sleep testing through benefit managers such as Carelon or EviCore, which often require a home sleep test (such as 95800 or 95806) before approving an in-lab study (95810 or 95811). For continued CPAP coverage, Medicare requires documented use of at least 4 hours a night on 70% of nights in a 30-day stretch during the first three months. Pulmonary rehab and home oxygen have their own Medicare documentation rules that need checking before billing.
Pulmonology coding details that affect payment
ICD-10 considerations
COPD codes separate an acute exacerbation (J44.1) from COPD with an acute lower respiratory infection (J44.0), and the infection is coded as well. Respiratory failure codes in J96 state acuity and whether hypoxia or hypercapnia is present, such as J96.01 for acute respiratory failure with hypoxia, which supports critical care. Idiopathic pulmonary fibrosis has its own code (J84.112), and pulmonary nodules are coded as R91.1 for a solitary nodule or R91.8 for other findings. Low-dose CT screening needs tobacco use documented with codes such as F17.210 (cigarette dependence) or Z87.891 (history of nicotine dependence), and sleep claims rely on G47.33 for obstructive sleep apnea.
Modifiers to watch
| 26 | Used on PFT and sleep study interpretations when the testing is performed in a hospital or another entity's lab. |
|---|---|
| TC | Billed by the sleep lab or testing site that owns the equipment when a different physician interprets the study. |
| FS | Required by Medicare on split or shared critical care and hospital visits, identifying the practitioner who performed the substantive portion. |
| KX | Used by DME suppliers on CPAP and oxygen claims to show the Medicare coverage criteria, including adherence, are documented. |
| 25 | Added to the E/M when a significant, separate evaluation occurs on the same day as a bronchoscopy or thoracentesis. |
Global periods
Thoracentesis (32554, 32555) and chest tube placement (32551) carry 0-day globals, like bronchoscopy, so a hospital visit the next day is separately billable. PFTs and sleep studies are diagnostic tests with no global period.
Medicare considerations
Medicare covers home oxygen under NCD 240.2, which requires qualifying blood gas or oxygen saturation results tested within a set window, and CPAP for obstructive sleep apnea under NCD 240.4. Pulmonary rehabilitation is covered for moderate to very severe COPD and certain other conditions, with session limits and a physician-directed program. Diagnostic tests performed in the office must meet the supervision level CMS assigns to each code.
Pulmonology billing KPIs to track
- PFT component accuracy. Bundled spirometry codes and wrong 26 or TC billing cause denials on the practice's most common tests.
- Critical care time documentation rate. Critical care claims without total time stated are easily downcoded on review.
- Sleep study authorization denials. In-lab studies performed without approval or a required home test first are hard to recover.
- Hospital charge lag. Rounds and consults captured late from the hospital are the largest source of delayed pulmonology claims.
Pulmonology billing audit checklist
- Confirm 94010 is not billed with 94060 on the same day.
- Check that DLCO and plethysmography are billed only when the report shows they were performed.
- Verify critical care notes state total time and that 99292 meets the payer's threshold.
- Review EBUS claims for the number of stations sampled and the matching code.
- Confirm sleep studies had authorization and, where required, a prior home sleep test.
- Check that LDCT screening orders document age, pack-years and smoking status.
How SFA runs pulmonology billing
We review your office, hospital and sleep lab claims to see where each setting is losing revenue.
We verify benefits and obtain authorizations for sleep studies, biologics and procedures before they are scheduled.
Coders apply component modifiers, critical care time rules and bronchoscopy bundling before submission, with a 24-hour target for clean claims after final review.
We appeal denials and track hospital charges so no inpatient or ICU visit goes unbilled.
The services that matter most for pulmonology
Medical Coding
PFT combinations, critical care time and EBUS station counts are where pulmonology claims are most often miscoded.
Learn moreEligibility Verification & Prior Authorization
Sleep studies, biologic drugs for asthma and some imaging need prior authorization before the service.
Learn moreDenial Management
Bundling and medical necessity denials on testing and critical care are common and often reversible.
Learn moreWhat practices typically see with SFA
Averages and selected client results. Your free audit shows where your own numbers stand today.
Target for the claims we manage, not a measured average.
Highest improvement seen in selected client results.
Largest drop in A/R days seen in selected client results.
Targeted for submission within 24 hours after final review.
From primary care and nurse practitioners to surgery and imaging.
We work inside the system your practice already uses.
Results vary by practice, specialty, payer mix, claim volume, billing history, documentation and other factors. Performance figures represent average or selected client results and are not guarantees of future performance. The 95% figure is a clean-claim target, not a measured cohort. The client-results page does not include a measurement period, starting collections, or practice size.
Pulmonology billing questions
Can we bill 94010 and 94060 together?
No. 94060 includes spirometry before and after a bronchodilator, so 94010 is not billed separately on the same day.
How much time is needed for 99292 with Medicare?
Medicare requires a total of 104 minutes of critical care before 99292 can be billed once. Most commercial payers follow CPT, which allows 99292 at 75 minutes.
Can we bill a visit on the same day as a bronchoscopy?
Bronchoscopy codes have a 0-day global, so an E/M on the same day is billable with modifier 25 only when it is significant and separate from the usual pre-procedure assessment. If the decision to do the procedure is made that day, that can support the visit.
Is lung cancer screening covered?
Medicare covers annual low-dose CT for patients 50 to 77 with at least a 20 pack-year history who currently smoke or quit within the past 15 years. A shared decision-making visit (G0296) is required before the first scan.
Do you bill sleep medicine?
Yes. We bill in-lab and home sleep studies, interpretations and follow-up visits, and we track CPAP adherence documentation for DME coverage.
Related specialties
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