OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedAmbetter GeorgiaPolicy CP.MP.242

Pulmonary Function Testing (Clinical Policy)

Customize your policy alerts

Sign up for Ambetter Georgia Policy CP.MP.242 alerts

Get alerted when Policy CP.MP.242 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Medical necessity criteria and coding guidance for pulmonary function tests (PFTs) for members aged three years and older under Ambetter Georgia.

Policy Summary

PayerAmbetter Georgia

PolicyPulmonary Function Testing

Policy CodePolicy CP.MP.242

Change TypeCriteria and coding updates (material)

Effective DateAug 1, 2026

Next Review DateN/A

Key ActionWhen billing PFT CPT codes, include one of the ICD-10-CM diagnosis codes from Table 1 to support medical necessity and verify prior authorization requirements per payer rules.

SourceLink

POLICY UPDATE CHANGES

Criteria I.A.1. and I.A.2. were updated regarding the presence or absence of lung dysfunction.

Criteria I.A.3. through I.A.6. were updated regarding assessment of severity, change in lung function, and surgical risk.

Criteria I.A.7.a and I.A.7.c were updated for clarity and to include nonreversibility in I.A.7.c; a note about repeat studies was added under I.A.7.c.

Multiple I.B criteria (I.B.1 through I.B.8) were updated regarding evaluation, early detection, assessment/response to therapy, perioperative evaluations, and tracking progression; a note about repeat testing was added under I.B.8.

Criteria I.C.1 through I.C.9 were updated regarding evaluation and follow-up of parenchymal lung diseases and related assessments.

CPT code 94150 was added to the CPT Code Table.

Multiple ICD-10 codes were added to ICD-10 Table 1, Table 2, Table 3, and Table 4; several codes were removed from ICD-10 Table 1.

Clarifying language added to Criteria I.E.2.c.

ages 3+member age threshold for coverage

94150CPT code explicitly added

severalICD-10 codes removed from Table 1

3CMS LCA/A docs cited (2024–2026)

multiple PFT typesTests covered

Coverage Criteria for Pulmonary Function Testing

Spirometry

Covered when ANY one of the following test-specific indications is met:

Spirometry Indications: Spirometry is medically necessary when any one of the following is present: (1) detection of the presence or absence of lung dysfunction suggested by history or clinically significant physical signs and symptoms; (2) detection of the presence or absence of lung dysfunction suggested by other abnormal diagnostic tests (e.g., radiography, arterial blood gas analysis); (3) quantifying the severity of known lung disease; (4) assessment of the change in lung function over time; (5) assessment of the change in lung function following administration of or a change in therapy; (6) assessment of the risk for surgical procedures known to affect lung function; (7) post-bronchodilator spirometry when at least one of the following is documented: a) signs or symptoms consistent with bronchospasm, b) spirometry without bronchodilator is abnormal, or c) reversibility or nonreversibility of bronchospasm has not been demonstrated.

Note: Repeat spirometry studies are covered only with documentation of clinically significant change necessitating adjustment or augmentation of therapy.

Lung volume tests

Covered when ANY one of the following indications is met:

Policy Summary

PayerAmbetter Georgia

PolicyPulmonary Function Testing

Policy CodePolicy CP.MP.242

Change TypeCriteria and coding updates (material)

Effective DateAug 1, 2026

Next Review DateN/A

Key ActionWhen billing PFT CPT codes, include one of the ICD-10-CM diagnosis codes from Table 1 to support medical necessity and verify prior authorization requirements per payer rules.

SourceLink

On This Page

Diffusion capacity (DLCO)

Covered when ANY one of the following indications is met:

DLCO Indications: Diffusion capacity (DLCO) testing is medically necessary when any one of the following is indicated: (1) evaluation and follow-up of parenchymal lung diseases associated with dusts, drug reactions, or sarcoidosis; (2) evaluation and follow-up of emphysema and cystic fibrosis; (3) differentiating between chronic bronchitis, emphysema, and asthma in members with obstructive patterns; (4) evaluation of pulmonary involvement in systemic diseases (e.g., rheumatoid arthritis, systemic lupus); (5) assisting in evaluation of some cardiovascular diseases (e.g., primary pulmonary hypertension, pulmonary edema, acute or recurrent thromboembolism); (6) prediction of arterial desaturation during exercise in COPD; (7) evaluation and quantification of disability associated with interstitial lung disease; (8) evaluation of effects of chemotherapy agents or other drugs known to induce pulmonary dysfunction; (9) evaluation of hemorrhagic disorders.

Pulmonary studies during exercise testing

Covered when ANY one of the following exercise-testing indications is met:

Pulmonary studies during exercise - simple: Simple pulmonary stress testing is medically necessary for: (a) measuring the degree of hypoxemia or desaturation that occurs with exertion; and (b) optimizing titration of supplemental oxygen for correction of hypoxemia. Examples include the six-minute walk test, the incremental shuttle walk test, and the endurance shuttle walk test.

Pulmonary studies during exercise - complex: Complex pulmonary exercise testing is medically necessary for: (a) distinguishing between cardiac and pulmonary causes for dyspnea; (b) determination of the need for and dose of ambulatory oxygen; (c) assisting in developing a safe exercise prescription for members with cardiovascular or pulmonary disease; (d) predicting the morbidity of lung resection; and (e) titration of optimal settings in selected patients who have physiologic pacemakers.

Medical necessity criteria (summary)

Policy I. criteria updated for clarity (detailed criteria text not present in this excerpt); PFTs are medically necessary for members/enrollees 3 years of age and above per prior revisions.

high-level criteria summary: Updated criteria address: detection of presence/absence of lung dysfunction; assessment of severity and change in lung function; assessment of surgical risk; evaluation and follow-up of parenchymal lung diseases; differentiation among chronic bronchitis, emphysema, and asthma; monitoring response to therapy; prediction of arterial desaturation during exercise; evaluation of drug-induced pulmonary dysfunction; and assessment related to hemorrhagic disorders.ages >= 3 years

Full detailed criteria (I.A–I.E) are present in the policy body; this excerpt summarizes updates and additions (including addition of CPT 94150 and ICD-10 Table updates).

Updated Indications and Assessment Criteria (I.A–I.C)

Policy updated coverage criteria sections I.A, I.B, I.C, and I.E addressing indications such as detection of lung dysfunction, severity assessment, monitoring change, perioperative risk, evaluation of parenchymal lung disease, and response to therapy.

Criteria I.A updates: The policy revisions clarify I.A.1–I.A.7 (presence/absence of lung dysfunction; assessment of severity; assessment of change in lung function; assessment of surgical risk; inclusion of nonreversibility in I.A.7.c; and added note on repeat studies), and update multiple I.B and I.C items related to early detection, evaluation and follow-up of parenchymal lung diseases, response to therapy, and perioperative evaluations.

Refer to the full policy sections I.A–I.E for the complete, detailed criteria.

Coding and Supported Diagnosis Codes

Covered CPT Codes (referenced)CPT

94010	Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation
94060	Bronchodilation responsiveness, spirometry as in 94010, pre- and post- bronchodilator administration
94070	Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents (e.g., antigen(s), cold air, methacholine)
94150	Vital capacity, total (separate procedure)
94200	Maximum breathing capacity, maximal voluntary ventilation
94375	Respiratory flow volume loop
94450	Breathing response to hypoxia (hypoxia response curve)
94617	Exercise test for bronchospasm, including pre- and post-spirometry and pulse oximetry
94618	Oximetry; with electrocardiographic recording(s) Pulmonary stress testing (e.g., 6-minute walk test) including measurement of heart rate, oximetry, and oxygen titration, when performed
94619	Exercise test for bronchospasm, including pre- and post-spirometry and pulse oximetry; without electrocardiographic recording(s)

1–10 of 16

1/2

Additional CPT Codes (referenced)CPT

94728	Distribution of ventilation and closing volumes (as referenced)
94729	Diffusing capacity (e.g., carbon monoxide)

Supported CPT CodesCPTCovered

94010	listed CPT code supported by ICD-10 Table 1
94060	listed CPT code supported by ICD-10 Table 1
94200	listed CPT code supported by ICD-10 Table 1
94375	listed CPT code supported by ICD-10 Table 1
94450	listed CPT code supported by ICD-10 Table 1
94617	listed CPT code supported by ICD-10 Table 1
94618	listed CPT code supported by ICD-10 Table 1
94619	listed CPT code supported by ICD-10 Table 1
94621	listed CPT code supported by ICD-10 Table 1
94680	listed CPT code supported by ICD-10 Table 1

1–10 of 16

1/2

ICD-10-CM codes supporting coverageICD-10Covered

A15.0	Tuberculosis of lung
A15.4	Tuberculosis of intrathoracic lymph nodes
A15.5	Tuberculosis of larynx, trachea and bronchus
A15.6	Tuberculous pleurisy
A15.7	Primary respiratory tuberculosis
A15.8	Other respiratory tuberculosis
A18.01	Tuberculosis of spine
A19.0	Acute miliary tuberculosis of a single specified site
A19.1	Acute miliary tuberculosis of multiple sites
A19.8	Other miliary tuberculosis

1–10 of 187

1/19

Diagnosis codes (sample from muscular/myotonic disorders)ICD-10

G71.13	Myotonic chondrodystrophy
G71.14	Drug induced myotonia
G71.19	Other specified myotonic disorders
G72.41	Inclusion body myositis [IBM]
G72.49	Other inflammatory and immune myopathies

Diagnosis codes — pulmonary hypertension and relatedICD-10

I27.1	Primary pulmonary hypertension = Kyphoscoliotic heart disease
I27.20	Pulmonary hypertension, unspecified
I27.21	Secondary pulmonary arterial hypertension
I27.22	Pulmonary hypertension due to left heart disease
I27.23	Pulmonary hypertension due to lung diseases and hypoxia
I27.24	Chronic thromboembolic pulmonary hypertension
I27.29	Other secondary pulmonary hypertension
I27.81	Cor pulmonale (chronic)
I27.82	Chronic pulmonary embolism
I27.83	Eisenmenger's syndrome

Cardiac failure and acute upper airway infection codesICD-10

I50.1	Left ventricular failure, unspecified
I50.21	Acute systolic (congestive) heart failure
I50.22	Chronic systolic (congestive) heart failure
I50.31	Acute diastolic (congestive) heart failure
I50.81	Right heart failure codes (I50.810–I50.814 series present)
J04.10	Acute tracheitis without obstruction
J04.11	Acute tracheitis with obstruction
J04.2	Acute laryngotracheitis

Pneumonia and acute bronchitis codesICD-10

J12.82	Pneumonia due to coronavirus disease 2019
J13	Pneumonia due to Streptococcus pneumoniae
J15.211	Pneumonia due to Methicillin susceptible Staphylococcus aureus
J15.212	Pneumonia due to Methicillin resistant Staphylococcus aureus
J15.3	Pneumonia due to other staphylococcus
J20.0	Acute bronchitis due to Mycoplasma pneumoniae
J20.1	Acute bronchitis due to Hemophilus influenzae

Chronic bronchitis, emphysema, COPD, and asthma codesICD-10

J41.0	Simple chronic bronchitis
J41.1	Mucopurulent chronic bronchitis
J42	Unspecified chronic bronchitis
J43.1	Panlobular emphysema
J43.2	Centrilobular emphysema
J44.0	COPD with (acute) lower respiratory infection
J44.9	Chronic obstructive pulmonary disease, unspecified
J45.20	Mild intermittent asthma, uncomplicated
J45.21	Mild intermittent asthma with (acute) exacerbation

Occupational, environmental, and other specified respiratory disease codesICD-10

J45.50	Severe persistent asthma, uncomplicated
J47.0	Bronchiectasis with acute lower respiratory infection
J60	Coalworker's pneumoconiosis
J61	Pneumoconiosis due to asbestos and other mineral fibers
J63.0	Aluminosis (of lung)
J64	Unspecified pneumoconiosis
J67.0	Farmer's lung
J67.8	Hypersensitivity pneumonitis due to other organic dusts
J68.0	Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors
J70.0	Acute pulmonary manifestations due to radiation

Interstitial lung disease codeICD-10

J84.10

Pulmonary fibrosis, unspecified

Interstitial and specific lung disease ICD-10 codesICD-10

J84.112	Idiopathic interstitial pneumonia, not otherwise specified = Idiopathic pulmonary fibrosis.
J84.113	Idiopathic interstitial pneumonia, not otherwise specified = Idiopathic non-specific interstitial pneumonitis.
J84.114	Idiopathic interstitial pneumonia, not otherwise specified = Acute interstitial pneumonitis.
J84.115	Respiratory bronchiolitis interstitial lung disease.
J84.116	Cryptogenic organizing pneumonia.
J84.117	Desquamative interstitial pneumonia.
J84.170	Desquamative interstitial pneumonia / Interstitial lung disease with progressive fibrotic phenotype
J84.178	Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere.
J84.2	Lymphoid interstitial pneumonia.
J84.81	Lymphangioleiomyomatosis.

1–10 of 17

1/2

Pleural and pneumothorax-related ICD-10 codesICD-10

J85.0	Gangrene and necrosis of lung.
J85.1	Abscess of lung with pneumonia.
J85.2	Abscess of lung without pneumonia.
J85.3	Abscess of mediastinum.
J86.0	Pyothorax with fistula.
J86.9	Pyothorax without fistula.
J90	Pleural effusion, not elsewhere classified.
J91.0	Malignant pleural effusion.
J91.8	Pleural effusion in other conditions classified elsewhere.
J92.0	Pleural plaque with presence of asbestos.

1–10 of 17

1/2

Postprocedural and tracheostomy complication ICD-10 codesICD-10

J95.02	Hemorrhage from tracheostomy stoma = Infection of tracheostomy stoma.
J95.03	Hemorrhage from tracheostomy stoma = Malfunction of tracheostomy stoma.
J95.04	Hemorrhage from tracheostomy stoma = Tracheo-esophageal fistula following tracheostomy.
J95.09	Hemorrhage from tracheostomy stoma = Other tracheostomy complication.
J95.1	Acute pulmonary insufficiency following thoracic surgery.
J95.2	Acute pulmonary insufficiency following nonthoracic surgery.
J95.3	Chronic pulmonary insufficiency following surgery.
J95.811	Postprocedural pneumothorax.
J95.812	Postprocedural air leak.
J95.821	Acute postprocedural respiratory failure.

1–10 of 14

1/2

Respiratory failure ICD-10 codesICD-10

J96.01	Acute respiratory failure with hypoxia.
J96.02	Acute respiratory failure with hypercapnia.
J96.10	Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia.
J96.11	Chronic respiratory failure with hypoxia.
J96.12	Chronic respiratory failure with hypercapnia.
J96.21	Acute and chronic respiratory failure with hypoxia.
J96.22	Acute and chronic respiratory failure with hypercapnia.
J96.90	Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia.
J96.91	Respiratory failure, unspecified with hypercapnia.
J96.92	Respiratory failure, unspecified with hypercapnia.

Other specified lung disorder ICD-10 codesICD-10

J98.01	Acute bronchospasm.
J98.09	Other diseases of bronchus, not elsewhere classified.
J98.11	Atelectasis.
J98.19	Other pulmonary collapse.
J98.2	Other pulmonary collapse (alternate listing).
J98.3	Interstitial emphysema / Compensatory emphysema.
J98.51	Mediastinitis.
J98.59	Other diseases of mediastinum, not elsewhere classified.
J98.6	Disorders of diaphragm.
J98.8	Other specified respiratory disorders.

Symptom and sign ICD-10 codes commonly associated with PFTsICD-10

R04.2	Hemoptysis.
R04.81	Acute idiopathic pulmonary hemorrhage in infants.
R04.89	Other hemoptysis-related code.
R05.1	Acute cough.
R05.2	Subacute cough.
R05.3	Chronic cough.
R05.4	Cough syncope.
R06.00	Dyspnea, unspecified.
R06.01	Orthopnea.
R06.02	Shortness of breath.

1–10 of 11

1/2

Findings and abnormal test result ICD-10 codesICD-10

R94.2	Abnormal results of pulmonary function studies.
R91.1	Solitary pulmonary nodule.
R91.8	Other nonspecific abnormal finding of lung field.
R06.89	Other abnormalities of breathing.

Trauma/thorax injury ICD-10 codesICD-10

S21.311A	Laceration without foreign body of right front wall of thorax with penetration into thoracic cavity, initial encounter.
S21.311D	Laceration without foreign body of right front wall of thorax with penetration into thoracic cavity, subsequent encounter.
S21.312D	Laceration without foreign body of left front wall of thorax with penetration into thoracic cavity, subsequent encounter.
S21.321A	Laceration with foreign body of right front wall of thorax with penetration into thoracic cavity, initial encounter.
S21.321D	Laceration with foreign body of right front wall of thorax with penetration into thoracic cavity, subsequent encounter.
S21.321S	Laceration with foreign body of right front wall of thorax with penetration into thoracic cavity, sequela.

Listed ICD-10 Codes (partial)ICD-10

S32.411S	Other injury of other specified intrathoracic organs, sequela
T53.5X1A	Toxic effect of chlorofluorocarbons, accidental (unintentional), initial encounter
T53.5X1D	Toxic effect of chlorofluorocarbons, accidental (unintentional), subsequent encounter
T53.5X1S	Toxic effect of chlorofluorocarbons, accidental (unintentional), sequela
T53.5X2A	Toxic effect of chlorofluorocarbons, intentional self-harm, initial encounter
T53.5X2D	Toxic effect of chlorofluorocarbons, intentional self-harm, subsequent encounter
T53.5X2S	Toxic effect of chlorofluorocarbons, intentional self-harm, sequela
T56.823A	Toxic effect of gadolinium, assault, initial encounter
T56.823D	Toxic effect of gadolinium, assault, subsequent encounter
T56.823S	Toxic effect of gadolinium, assault, sequela

1–10 of 21

1/3

Covered CPT Codes (referenced)CPTCovered

94070	Referenced in ICD-10 Table 3/4; supports medical necessity for selected respiratory diagnoses
94617	Referenced as supported by ICD-10 Table 2 and other tables
94618	Referenced as supported by ICD-10 Table 2 and other tables
94619	Referenced as supported by ICD-10 Table 2 and other tables
94621	Referenced as supported by ICD-10 Table 2 and other tables
94150	Added to CPT Code Table (document notes addition)

ICD-10 codes supporting medical necessityICD-10

R06.02	Shortness of breath
R06.09	Other forms of dyspnea
R06.2	Wheezing
R06.82	Tachypnea, not elsewhere classified
R06.83	Snoring
R06.89	Other abnormalities of breathing
E66.2	Morbid (severe) obesity with alveolar hypoventilation
J44.9	Chronic obstructive pulmonary disease, unspecified
J45.20	Mild intermittent asthma, uncomplicated
J45.21	Mild intermittent asthma with (acute) exacerbation

1–10 of 25

1/3

Added CPT CodesCPTCovered

94150

added to CPT Code Table

ICD-10 Table 4 entriesICD-10

J12.82	listed in ICD-10 Table 4 for specific CPT codes
J45.990	listed in ICD-10 Table 4 for specific CPT codes
Z86.16	listed in ICD-10 Table 4 for specific CPT codes

Selected ICD-10 Table 1 additions (partial list)ICD-10

A18.01	added to ICD-10 Table 1
A19.0	added to ICD-10 Table 1
A19.1	added to ICD-10 Table 1
A19.8	added to ICD-10 Table 1
A20.2	added to ICD-10 Table 1

ICD-10 Table 1 removals (partial list)ICD-10Not Covered

A15.9	removed from ICD-10 Table 1
B38.2	removed from ICD-10 Table 1
B39.2	removed from ICD-10 Table 1

Referenced LCAs/Articlesmixed

A57224	Local coverage article referenced (respiratory care)
A56717	Local coverage article referenced (respiratory therapy)
A56784	Local coverage article referenced (pulmonary stress testing)
L34149	Local coverage determination referenced (respiratory care)
L34430	Local coverage determination referenced (respiratory therapy)

Key thresholds and requirements

Member age threshold>= 3 years

Covered tests (examples)Spirometry, lung volume tests, DLCO (diffusing capacity), lung compliance studies, pulmonary studies during exercise

Post-bronchodilator spirometry documentationRequired when signs/symptoms of bronchospasm, abnormal baseline spirometry, or undemonstrated reversibility are documented; repeat studies covered only with clinically significant change and documentation

Repeat total lung volume testingNot typically clinically necessary (note in policy)

ICD-10 linkage for CPT codesClaims for listed pulmonary function CPT codes must include an ICD-10-CM diagnosis from policy Table 1 to support medical necessity

Placeholder / Not applicable details

Not applicable in this excerptNo additional threshold information is provided in the excerpt

Abnormal PFT result coding exampleR94.2 (Abnormal results of pulmonary function studies) appears in diagnosis listings

Trauma/thorax injury codes presentMultiple S21.* codes for thoracic lacerations and sequela are listed in the ICD-10 listings

Use of listed diagnosesDiagnosis codes in the listing are intended to support CPT billing but no explicit threshold criteria are given in this section

Policy alignment and revision dates

Policy alignment dates (LCAs/Articles)Codes aligned with LCAs revised Jan 01, 2025; and LCAs revised Oct 01, 2024; document notes alignment with LCAs/A articles revised 2024–2026

CPT table changeCPT code 94150 was added to the CPT Code Table

ICD-10 Table updatesMultiple ICD-10 codes were added to Tables 1–4 and several codes were removed from Table 1 (document lists specific additions/removals)

Criteria sections updatedCriteria I.A–I.C and I.E were updated for clarity including presence/absence of dysfunction, severity assessment, change over time, surgical risk, and notes about repeat testing

Provider Actions, Documentation and Billing Guidance

Prior Authorization

Verify PA requirements for listed PFT CPT codes

This policy lists specific CPT procedure codes for pulmonary function testing; verify whether your Health Plan requires prior authorization for any of these CPT-coded PFT services before scheduling or submitting claims.

Referenced CPT codes include (examples): 94010, 94060, 94070, 94150, 94200, 94375, 94450, 94617–94619, 94621, 94680–94681, 94690, 94726–94729.

Billing Rule

Code claims with an ICD-10-CM diagnosis from Table 1

When requesting coverage or submitting claims for the CPT procedures listed in the policy, include an appropriate ICD-10-CM diagnosis code from ICD-10 Table 1 that supports medical necessity for the specific CPT code.

Table 1 links CPT codes (e.g., 94010, 94060, 94200, 94375, 94450, 94617–94619, 94621, 94680–94681, 94690, 94726–94729) to supporting ICD-10-CM codes.

Prior Authorization

No PA rules stated in this excerpt

No prior authorization requirements are specified within the provided excerpt of this policy; follow Health Plan administrative policies to determine if PA is required for PFTs.

Prior Authorization

PA not specified here — consult plan documents

The excerpt does not define any prior authorization rules for pulmonary function testing; consult the member’s coverage documents or the Health Plan’s administrative policies for PA processes.

Prior Authorization

No PA requirements in this section

This section contains no stated prior authorization requirements; providers remain responsible for confirming PA per the Health Plan and member benefit terms.

Documentation Required

Support CPT requests with ICD-10 codes from policy tables

Use the ICD-10-CM diagnosis codes provided in the policy (Table 1 and other ICD-10 tables) to support medical necessity for the listed CPT procedures when requesting coverage or submitting claims.

ICD-10 Table 1 supports CPT codes such as 94010, 94060, 94200, 94375, 94450, 94617–94619, 94621, 94680–94681, 94690, 94726–94729.

Prior Authorization

PA/coverage may reference CPT-to-ICD-10 table matches

Certain CPT codes (for example 94070, 94617–94619, 94621 and the added 94150) are mapped to specific ICD-10 table listings (including Table 4); prior authorization or adjudication may reference these CPT-to-ICD-10 table pairings.

ICD-10 Table 4 specifically supports CPTs 94070, 94617, 94618, 94619, and 94621.
CPT 94150 was added to the CPT Code Table per the revisions.

Note

PA governed by Health Plan policies and coverage documents

This clinical policy is a guide to medical necessity used to assist coverage decisions; any prior authorization requirements are governed by the Health Plan’s administrative policies and the member’s coverage documents.

Coverage decisions are subject to terms, conditions, exclusions and limitations of the applicable coverage documents.

Documentation Required

Document the indication that meets policy criteria

Documentation must record the clinical indication that meets one of the policy’s medical necessity criteria (e.g., symptoms, abnormal diagnostic tests, quantification of disease, assessment of therapy response, or preoperative risk).

Examples of acceptable indications are enumerated in the spirometry and lung volume criteria (detection of dysfunction, dyspnea, tracking progression, assessment of therapy).

Documentation Required

Document qualifying condition for post-bronchodilator spirometry

For post-bronchodilator spirometry, the medical record must document at least one qualifying condition: signs/symptoms consistent with bronchospasm, abnormal pre-bronchodilator spirometry, or that reversibility/nonreversibility of bronchospasm has not been demonstrated.

Note: Repeat post-bronchodilator studies are covered only with documentation of a clinically significant change necessitating therapy adjustment.

Billing Rule

Use a Table 1 ICD-10 code to support billing of listed CPTs

Claims for listed pulmonary function CPT codes must be supported by one of the ICD-10-CM diagnosis codes in ICD-10 Table 1; include an appropriate Table 1 code on the claim to substantiate medical necessity.

Table 1 lists supporting ICD-10-CM codes for CPTs including 94010, 94060, 94200, 94375, 94450, 94617–94619, 94621, 94680–94681, 94690, 94726–94729.

Billing Rule

Code abnormal PFT results with appropriate ICD-10 (e.g., R94.2)

Use diagnosis codes such as R94.2 (‘Abnormal results of pulmonary function studies’) where applicable to describe abnormal PFT results; accurate coding of abnormal findings is necessary for claim adjudication.

R94.2 is specifically listed in the policy among findings/abnormal test result codes.

Documentation Required

Support medical necessity with clinical documentation

Maintain documentation that demonstrates medical necessity consistent with the policy’s clinical criteria and generally accepted standards of medical practice; the policy is a guide and does not replace provider clinical judgment.

Documentation should support the specific criterion used (e.g., detection of dysfunction, assessment of severity, response to therapy, preoperative risk).

Denial Risk

Code lists are informational — confirm coverage

Inclusion of a code in the policy does not guarantee coverage; providers should confirm current coding guidance and payer coverage rules prior to claim submission.

The policy states that CPT codes are provided for informational purposes and inclusion/exclusion of codes does not guarantee coverage.

Denial Risk

Use supported ICD-10 codes or risk denial

Claims for the pulmonary function CPT codes listed must be supported by an appropriate ICD-10-CM diagnosis from the policy tables; failure to use a supported diagnosis may result in claim denial or processing issues.

The policy requires ICD-10 Table 1 codes to support CPTs and emphasizes accurate coding for adjudication.

Denial Risk

Denial risk if criteria or table-listed diagnoses not met

Using diagnosis codes that are not listed in the applicable ICD-10 tables (or failing to meet updated clinical criteria I.A–I.C) may lead to denial of services during adjudication.

The policy notes services may be denied if not meeting updated clinical criteria or when diagnosis codes are not in the referenced ICD-10 tables.

Note

Coverage governed by plan documents and law

Coverage determinations are subject to the terms, exclusions and limitations of the member’s coverage documents and applicable laws; this policy guides medical necessity but does not guarantee payment.

Refer to the evidence of coverage, certificate of coverage, policy, or contract of insurance for final benefit determinations.

Note

Definitions and Test Terminology

Vital capacity (VC)

DefinitionMaximum volume of air exhaled after maximum inspiration; measured as FVC or SVC.

Measured asForced Vital Capacity (FVC) or Slow Vital Capacity (SVC).

RelevanceUsed to quantify restrictive and obstructive ventilatory defects in spirometry and lung-volume testing.

Functional residual capacity (FRC)

DefinitionVolume of air remaining in chest at the end of a tidal breath.

RelationFRC equals residual volume (RV) plus expiratory reserve volume (ERV).

UseReported in lung-volume testing to assess restrictive vs obstructive patterns.

Residual volume (RV)

DefinitionVolume of air remaining in chest after maximal exhalation.

RoleComponent of total lung capacity (TLC); used in lung-volume measurements.

MeasurementDetermined directly (e.g., plethysmography) or by calculation with other lung volumes.

ICD-10 Table 1 definition

DefinitionICD-10 Table 1: set of ICD-10-CM diagnosis codes that support medical necessity for specified pulmonary function CPT codes.

PurposeTable 1 codes must accompany claims for listed CPT codes (e.g., 94010, 94060, 94200, 94375, 94450, 94617–94619, 94621, 94680–94690, 94726–94729).

Location in policyListed under 'ICD-10-CM Diagnosis Codes that Support Coverage Criteria' (ICD-10 Table 1).

Pulmonary hypertension and related heart disease codes

ScopeIncludes ICD-10 codes in the I27.x range and related I3x entries listing primary and secondary pulmonary hypertension, cor pulmonale, chronic pulmonary embolism, Eisenmenger's syndrome, and related pulmonary vascular disorders.

ExamplesI27.1, I27.20–I27.29, I27.81–I27.83; related I28.x and I37.x entries referenced for pulmonary vascular and valve conditions.

Clinical useUsed to support medical necessity for PFT CPT codes when pulmonary vascular disease is the indication.

Idiopathic interstitial pneumonia / related ILD codes

ContentMultiple ICD-10 codes in the J84.112–J84.178 series and related entries defining idiopathic interstitial pneumonias and specific ILDs (e.g., J84.112–J84.117, J84.170, J84.178, J84.2, J84.81–J84.843, J84.848, J84.89).

ExamplesJ84.112 (idiopathic pulmonary fibrosis), J84.116 (cryptogenic organizing pneumonia), J84.81–J84.82 (lymphangioleiomyomatosis, Langerhans cell histiocytosis).

PurposeThese codes support PFTs including DLCO and other tests for evaluation and follow-up of parenchymal lung disease.

Postprocedural and respiratory failure codes

Included code rangesJ95.* and J96.* series covering postprocedural respiratory complications and acute/chronic respiratory failure (e.g., J95.02–J95.84 entries; J96.01–J96.22, J96.90–J96.92).

ExamplesJ95.821–J95.822 (acute and chronic postprocedural respiratory failure); J96.01 (acute respiratory failure with hypoxia); J96.11 (chronic respiratory failure with hypoxia).

UseUsed in ICD-10 tables to indicate respiratory failure or postprocedural complications as supporting diagnoses for selected PFTs.

PFT indications and uses

Indications summaryEvaluate presence/absence of lung dysfunction; assess severity and changes in lung function; assess perioperative risk; monitor response to therapy and progression of disease.

Specific usesIncludes detection of lung dysfunction suggested by history or tests, quantifying disease severity, assessing bronchodilator response, DLCO for parenchymal disease assessment, and exercise testing for exertional desaturation.

Documentation requirementClaims for listed CPT codes must include an ICD-10-CM diagnosis from Table 1 to support medical necessity.

Pulmonary function testing

DefinitionPulmonary function testing (PFT): a group of tests including spirometry (pre/post-bronchodilator), lung volumes, diffusing capacity (DLCO), flow-volume loops, lung compliance studies, and pulmonary exercise testing used to evaluate respiratory symptoms, quantify lung dysfunction, monitor disease progression, and assess response to therapy.

Common testsSpirometry (94010, 94060), lung volumes (plethysmography 94726; gas dilution 94727), DLCO (94729), exercise studies (94617–94619, 94621).

Policy scopePFTs are medically necessary for members aged three years and older when meeting criteria specified in policy CP.MP.242.

Policy Update / Revision History

2026-08-01policy_effectiveLatest

Policy CP.MP.242 became effective with multiple substantive clinical criteria revisions (I.A–I.C and I.E), addition of CPT code 94150, and numerous ICD-10 table updates and removals.

2025-01-01coding_alignment

Policy coding aligned with CMS local coverage articles A57224 and A57225 (revised Jan 01, 2025) as noted in background coding alignment.

2024-10-01coding_alignment

Policy coding aligned with CMS local coverage articles A56717 and A56784 (revised Oct 01, 2024) as noted in background coding alignment.

2024-03-25approval

Document shows an approval metadata date of 03/25 associated with listed ICD-10 additions and updates.

icd10_table_changes

Multiple ICD-10 codes were added to ICD-10 Table 1–4 and several codes were removed from ICD-10 Table 1 as detailed in the policy update.

Pulmonary Function Testing (Clinical Policy)

Sign up for Ambetter Georgia Policy CP.MP.242 alerts

Coverage Criteria for Pulmonary Function Testing

Coding and Supported Diagnosis Codes

Provider Actions, Documentation and Billing Guidance

Definitions and Test Terminology

Background and Scope

Policy Update / Revision History