Effective Date: October 14, 2019

Purpose:
Provide guidelines for the reimbursement of pulmonary diagnostic procedures (CPT codes 94010 through 94799) when billed with an Evaluation and Management (E&M) code (99201-99215, 99241-99245, 99281-99285, 99304-99318, 99324-99337, 99341-99350). This policy shall apply to professional providers.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Modifier -25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.

Policy:
In alignment with CMS guidelines, Horizon NJ Health shall not consider for reimbursement an Evaluation and Management (E&M) code billed with a pulmonary diagnostic procedure on the same date by the same provider unless there is a modifier -25 appended to the E&M code to indicate a significant separately identifiable service was performed which is unrelated to the pulmonary diagnostic procedure.

Note: The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon NJ Health shall deny an Evaluation and Management (E&M) service when billed with CPT Codes 94010-94799 (Pulmonary function testing) unless reported with modifier -25 indicating the E&M is a significant separately identifiable evaluation and management service. The documentation must support the application of Modifier -25.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

CMS National Correct Coding Policy Manual, Chapter 11, Section J “Pulmonary Services” cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

Local Coverage Determination (LCD): Pulmonary Function Testing (L35360) cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35360&ver=42&Date=&DocID=L35360&bc=iAAAABAAAAAA&

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services