Pulmonology Medical Billing Services —
PFT, Sleep Studies & All Lung Codes

When the pulmonology practice owns and operates the testing equipment (spirometer, body plethysmograph, DLCO testing system), both the technical component (running the test, equipment use, technologist time) and the professional component (physician interpretation and written report) are billable. This is global billing — or separate TC and -26 billing, which some payer contracts prefer. When the patient goes to a hospital PFT lab or independent respiratory therapy department for the test and the pulmonologist only reads the printed results, that's professional component (-26) only. The distinction depends on who owns the equipment and where the test is performed.

Endobronchial ultrasound-guided transbronchial aspiration (EBUS-TBNA) uses different codes than standard bronchoscopy. 31652 covers EBUS with mediastinal and/or peribronchial lymph node aspiration — 1 or 2 stations; 31653 covers 3 or more stations. When EBUS is combined with standard bronchoscopy procedures (biopsy, BAL), the EBUS code is the primary and the standard bronchoscopy procedures are add-ons. Navigational bronchoscopy (31660–31661) has its own separate code set. We review the operative report and build the correct code combination for each bronchoscopy type.

In-lab polysomnography (95810) requires a minimum of 6 channels of physiological data recorded and documented: typically EEG, EOG, EMG, ECG, respiratory effort, oxygen saturation, and airflow. 95808 requires only 4 channels. Home sleep testing (95800) requires 4 or more channels recorded without EEG (so no sleep staging) — specifically, it measures airflow, oximetry, respiratory effort, and sometimes body position and heart rate. The clinical documentation must include the specific channels recorded, total recording time, and total sleep time. Split-night studies require documentation that both the diagnostic phase met criteria for OSA and the titration phase achieved adequate CPAP pressure.

Pulmonary rehabilitation is covered by Medicare for patients with moderate-to-severe COPD (GOLD 2+), post-acute exacerbation, or post-COVID respiratory impairment. Medicare covers up to 36 sessions per year (72 under exceptional circumstances) using codes G0237 (therapeutic exercises), G0238 (respiratory therapy), and G0239 (individualized PR, additional components). Commercial coverage varies significantly. Authorization requirements include: post-bronchodilator spirometry confirming obstructive disease, physician referral with diagnosis documentation, and prior authorization from the payer for a defined number of sessions. We obtain authorization before the first session and manage session-count tracking to support re-authorization requests.

Yes. Outpatient-inpatient hybrid billing is common for pulmonologists. The billing distinction: outpatient clinic uses office E&M codes (99202–99215) or pulmonary function testing codes; ICU rounding uses critical care codes (99291/99292), subsequent hospital care (99231–99233), or initial hospital care (99221–99223) depending on the level of care and whether the patient meets critical care criteria. When the same pulmonologist rounds on both critically ill and stable ICU patients, critical care time must be separately documented for qualifying patients — you cannot apply critical care codes to ICU rounding unless the patient's condition meets the critical care definition (life-threatening illness or injury requiring constant physician availability).

The base diagnostic bronchoscopy code (31622) increases in value with each additional documented procedure: brushings (31623), bronchoalveolar lavage (31624), biopsy (31625), transbronchial biopsy with fluoroscopic guidance (31628), transbronchial needle aspiration (31629), and EBUS-guided sampling (31652/31653). A bronchoscopy operative report documenting BAL, transbronchial biopsy, and TBNA should generate four codes — most billing only captures one or two because it codes from the procedure order instead of the operative report. A dedicated airway procedure coder reviews every bronchoscopy report and maps documented procedures to the complete code set before submission.

Medicare's definition of critical care time is specific: it must be spent at the bedside or on the unit floor managing an acute, life-threatening illness, and it excludes time spent teaching residents (unless the teaching physician standard is separately met), time spent in family conferences, time spent charting or on administrative work, and time spent on floor activities not directly tied to managing the acute illness. Documentation that simply states a total number of minutes "managing the patient" without specifying which activities occurred overstates what's actually billable — and it's exactly what RAC auditors look for when reviewing critical care claims. We review critical care documentation against these criteria before 99291/99292 is billed, and flag vague documentation for physician clarification first.