Pulmonary Function Testing (PFT)
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Medical necessity criteria and coding guidance for pulmonary function testing (spirometry, lung volumes, DLCO, exercise testing and related PFTs) for members aged three years and above affiliated with Centene/AZ Complete Health.
PFTs are medically necessary for members/enrollees 3 years of age and above.
Multiple ICD-10 codes were added to ICD-10 Table 1 and other tables (examples listed in revision notes).
Multiple ICD-10 diagnosis codes were added to ICD-10 Table 1 and other tables across revisions (examples include B44.81, D86.81, I42.0- I42.8 and many others).
Criteria I. and subcriteria (I.A, I.B, I.C, I.E) were updated for clarity, including adding specification of type and degree of pulmonary dysfunction and nonreversibility language.
CPT code 94150 and other CPT/ICD-10 table alignments were added or updated (e.g., ICD-10 Table 4 mapping coverage for specific CPT codes).
A large set of ICD-10 codes were removed from ICD-10 Table 1 and Table 2 (examples listed in the log).
Coverage Criteria for Pulmonary Function Testing
inv-01: Medically Necessary Indications
Covered when ANY of the following test-specific indications are met (members age 3+):
Repeat spirometry studies are covered only with clinically significant change documented that necessitates adjustment or augmentation of therapy.
Repeat testing of total lung volume is not typically clinically necessary.
inv-02: Medical Necessity — general statement
Policy indicates PFTs are medically necessary when they serve specified clinical purposes and are supported by appropriate diagnosis codes:
Documentation should include a supported ICD-10-CM diagnosis from the relevant ICD-10 table that justifies the requested PFT CPT code(s).
inv-03: Updated Medical Necessity Criteria (I. and subcriteria)
Policy I. and subcriteria were updated; covered uses include evaluation, severity assessment, response to therapy, pre/postoperative risk assessment, disease progression tracking, and specific disease evaluations.
Includes nonreversibility language for post-bronchodilator testing and a Note that repeat studies are covered only with clinically significant change (I.A.7.c.).
Minor rewording to improve clarity; see full policy for enumerated subcriteria.
Criteria I.C.1 through I.C.9 were revised for clarity and scope; see full policy for details.
Repeat measurement of total lung volume is generally not required for routine management. The policy notes that repeat testing of total lung volume is not typically clinically necessary, and repeat studies should be performed only when there is a documented, clinically significant change in the member’s condition that would alter management or when specifically indicated by the criteria in the full policy.[3]
The excerpt included in this segment primarily provides an enumerated list of ICD-10 diagnosis codes (examples shown include malignant neoplasms of lung and mediastinum). This portion does not itself state explicit coverage determinations or medical necessity rationale; it supplies diagnosis code options to be used with the policy’s clinical criteria and coding tables.[18]
Within this excerpt no explicit coverage exclusions are declared. The text is composed largely of diagnosis code listings (for example, postprocedural respiratory and tracheostomy complication codes) that are intended to document clinical indications for pulmonary function testing rather than to enumerate exclusions.[36]
The policy language was revised to remove the prior distinction between spirometry performed for diagnostic purposes and spirometry performed for monitoring. The revision note states that the demarcation of spirometry indications as diagnostic versus monitoring purposes was removed from the medical necessity statement.[71]
Revision logs document that extensive lists of ICD-10 diagnosis codes were removed from the ICD-10 coverage tables. The revision notes identify multiple specific code ranges and individual codes that were deleted from Table 1 and related tables; providers should reference the current ICD-10 tables in the full policy for the active code set.[79][80]
All coverage is governed by the contractual terms of the applicable coverage documents. The policy states that coverage and administration of benefits are subject to the Health Plan’s terms, conditions, exclusions and limitations, and that state Medicaid provisions supersede this policy where conflicts exist.[92]
Revision notes and log entries identify specific ICD-10 codes removed from ICD-10 Table 3 (examples cited elsewhere in the document include codes such as J44.0, J44.89, J45.990, J95.84, and R06.02–R06.2). These removed entries indicate diagnoses that are no longer mapped in Table 3 for support of CPT code 94070; consult the updated ICD-10 tables in the policy for the current mappings.[79][81]
Coding: CPT and ICD-10 Tables
| 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 administration of 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; with electrocardiographic recording(s). |
| 94618 | 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). |
| Diffusing capacity (e.g., carbon monoxide, membrane) — referenced but specific CPT not listed in this segment. |
| A15.0 | Tuberculosis of lung |
| A15.4 | Tuberculosis of intrathoracic lymph nodes |
| A15.5 | Tuberculosis of larynx, trachea and bronchus |
| C34.2 | Malignant neoplasm of middle lobe, bronchus or lung |
| C34.31 | Malignant neoplasm of lower lobe, right bronchus or lung |
| C34.32 | Malignant neoplasm of lower lobe, left bronchus or lung |
| C34.81 | Malignant neoplasm of overlapping sites of right bronchus and lung |
| C34.82 | Malignant neoplasm of overlapping sites of left bronchus and lung |
| C37 | Malignant neoplasm of thymus |
| C38.1 | Malignant neoplasm of anterior mediastinum |
| C38.2 | Malignant neoplasm of posterior mediastinum |
| C38.4 | Malignant neoplasm of pleura |
| C38.8 | Malignant neoplasm of overlapping sites of heart, mediastinum and pleura |
| J94.2 | Hemothorax |
| J94.8 | Other specified pleural conditions |
| J95.01 | Hemorrhage from tracheostomy stoma |
| J95.02 | Infection of tracheostomy stoma |
| J95.03 | Malfunction of tracheostomy stoma |
| J95.04 | Tracheo-esophageal fistula following tracheostomy |
| J95.09 | 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 |
| K76.81 | Hepatopulmonary syndrome |
| M05.111 | Rheumatoid lung disease with rheumatoid arthritis of right shoulder |
| M05.112 | Rheumatoid lung disease with rheumatoid arthritis of left shoulder |
| M05.121 | Rheumatoid lung disease with rheumatoid arthritis of right elbow |
| M05.122 | Rheumatoid lung disease with rheumatoid arthritis of left elbow |
| M05.131 | Rheumatoid lung disease with rheumatoid arthritis of right wrist |
| M05.132 | Rheumatoid lung disease with rheumatoid arthritis of left wrist |
| M05.141 | Rheumatoid lung disease with rheumatoid arthritis of right hand |
| M05.142 | Rheumatoid lung disease with rheumatoid arthritis of left hand |
| M05.151 | Rheumatoid lung disease with rheumatoid arthritis of right hip |
| M41.112 | Juvenile idiopathic scoliosis, cervical region |
| M41.113 | Juvenile idiopathic scoliosis, cervicothoracic region |
| M41.114 | Juvenile idiopathic scoliosis, thoracic region |
| M41.115 | Juvenile idiopathic scoliosis, thoracolumbar region |
| M41.116 | Juvenile idiopathic scoliosis, lumbar region |
| M41.117 | Juvenile idiopathic scoliosis, lumbosacral region |
| M41.122 | Adolescent idiopathic scoliosis, cervical region |
| M41.123 | Adolescent idiopathic scoliosis, cervicothoracic region |
| M41.124 | Adolescent idiopathic scoliosis, thoracic region |
| M41.125 | Adolescent idiopathic scoliosis, thoracolumbar region |
| O08.2 | Embolism following ectopic and molar pregnancy |
| O74.0 | Aspiration pneumonitis due to anesthesia during labor and delivery |
| O74.1 | Other pulmonary complications of anesthesia during labor and delivery |
| O89.01 | Aspiration pneumonitis due to anesthesia during the puerperium |
| O89.09 | Other pulmonary complications of anesthesia during the puerperium |
| R04.2 | Hemoptysis |
| R04.81 | Acute idiopathic pulmonary hemorrhage in infants |
| R04.89 | Hemorrhage from other sites in respiratory passages |
| R05.1 | Acute cough |
| R05.2 | Subacute cough |
| R91.8 | Other nonspecific abnormal finding of lung field |
| R94.2 | Abnormal results of pulmonary function studies |
| 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 |
| S21.311S | Laceration without foreign body of right front wall of thorax with penetration into thoracic cavity, sequela |
| S21.312A | Laceration without foreign body of left front wall of thorax with penetration into thoracic cavity, initial encounter |
| S21.312D | Laceration without foreign body of left front wall of thorax with penetration into thoracic cavity, subsequent encounter |
| S21.312S | Laceration without foreign body of left front wall of thorax with penetration into thoracic cavity, sequela |
| 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 |
| S26.09XA | Other injury of heart with hemopericardium, initial encounter |
| S26.09XD | Other injury of heart with hemopericardium, subsequent encounter |
| S26.09XS | Other injury of heart with hemopericardium, sequela |
| S26.11XA | Contusion of heart without hemopericardium, initial encounter |
| S26.11XD | Contusion of heart without hemopericardium, subsequent encounter |
| S26.11XS | Contusion of heart without hemopericardium, sequela |
| S26.12XA | Laceration of heart without hemopericardium, initial encounter |
| S26.12XD | Laceration of heart without hemopericardium, subsequent encounter |
| S26.12XS | Laceration of heart without hemopericardium, sequela |
| S26.19XA | Other injury of heart without hemopericardium, initial encounter |
| 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 |
| T53.5X3A | Toxic effect of chlorofluorocarbons, assault, initial encounter |
| T53.5X3D | Toxic effect of chlorofluorocarbons, assault, subsequent encounter |
| T53.5X3S | Toxic effect of chlorofluorocarbons, assault, sequela |
| T53.5X4A | Toxic effect of chlorofluorocarbons, undetermined, initial encounter |
| E66.2 | Morbid (severe) obesity with alveolar hypoventilation. |
| 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. |
| Z79.899 | Other long term (current) drug therapy. |
| J44.9 | Chronic obstructive pulmonary disease, unspecified. |
| J45.20 | Mild intermittent asthma, uncomplicated. |
| J45.21 | Mild intermittent asthma with (acute) exacerbation. |
| J45.22 | Mild intermittent asthma with status asthmaticus. |
| J45.30 | Mild persistent asthma, uncomplicated. |
| J45.31 | Mild persistent asthma with (acute) exacerbation. |
| J45.32 | Mild persistent asthma with status asthmaticus. |
| J45.40 | Moderate persistent asthma, uncomplicated. |
| J45.41 | Moderate persistent asthma with (acute) exacerbation. |
| J45.42 | Moderate persistent asthma with status asthmaticus. |
| J12.82 | Pneumonia due to coronavirus disease 2019. |
| J45.990 | Exercise induced bronchospasm. |
| Z86.16 | Personal history of COVID-19. |
| B44.81 | |
| D86.81 | |
| I42.0-I42.8 | |
| J84.842 | |
| J84.843 | |
| M41.116 | |
| M41.117 | |
| M41.126 | |
| M41.127 | |
| M41.26 |
| 94150 | Added to CPT Code Table |
| B44.81 | ICD-10 diagnosis code added to Table 1 |
| D86.81 | ICD-10 diagnosis code added to Table 1 |
| I42.0 | ICD-10 diagnosis code range I42.0 - I42.8 added to Table 1 |
| E66.2 | Added to ICD-10 Table 2 |
| R06.02 | Added to ICD-10 Table 2 |
| R06.83 | Added to ICD-10 Table 2 |
| R05.9 | Added to ICD-10 Table 3 |
| J12.82 | Included in ICD-10 Table 4 for CPT codes 94070, 94617-94619, 94621 |
| J45.990 | Included in ICD-10 Table 4 for CPT codes 94070, 94617-94619, 94621 |
| Z86.16 | Included in ICD-10 Table 4 for CPT codes 94070, 94617-94619, 94621 |
| A15.9 | Removed from ICD-10 Table 1 |
| B38.2 | Removed from ICD-10 Table 1 |
| C34.00 | Removed from ICD-10 Table 1 |
Provider Actions, Prior Authorization & Documentation
Check payer for prior authorization; codes are informational
Refer to the member's Health Plan for any prior authorization (PA) requirements; CPT codes listed in the policy are for informational purposes only and inclusion does not guarantee coverage. Providers should confirm PA rules with the plan before submitting requests.
No explicit prior authorization requirements in these excerpts
The policy text in these sections does not state explicit prior authorization requirements; it lists procedure and diagnosis codes and medical necessity criteria but directs providers to payer administrative policies for PA rules.
- No specific PA process or required documentation for authorization is defined in these chunks.
- Verify plan-level PA procedures if needed.
No PA specified in this segment
This segment contains diagnosis and coding information but does not specify prior authorization requirements for the listed services.
- Only ICD-10 diagnosis code lists and code descriptions are provided in this excerpt.
- Consult the Health Plan for any PA determination.
Include policy-listed diagnosis codes with authorization requests
When requesting authorization for PFTs, ensure the billed CPT code is supported by an ICD-10-CM diagnosis from the policy's ICD-10 tables that map to that CPT; certain CPTs are explicitly linked to specific ICD-10 Tables.
Verify code-to-diagnosis mapping and LCA alignment before submission
Confirm that CPT-to-diagnosis mappings in the policy align with referenced Medicare Local Coverage Articles (LCAs) and that any LCA requirements are met before submission.
- CPT 94150 and other CPT/ICD alignments were updated to align with LCAs A57224/A57225 and A56717/A56784.
- Review the referenced LCAs and payer guidance to confirm coding alignment.
Prior authorization may be required — follow plan procedures
The Health Plan may require prior authorization according to its administrative policies; providers must follow plan-specific authorization procedures and coverage documents.
- This clinical policy does not replace plan-level PA or administrative rules.
- Contact the payer for PA requirements and follow their submission process.
Document clinical indication and rationale
Document the clinical indication for the requested PFT in the medical record — include signs/symptoms, abnormal diagnostic test results, severity of known lung disease, change in function or therapy, pre/postoperative risk assessment, or other listed indications per the test type.
- For spirometry: indication items such as detection of dysfunction, quantifying severity, assessing change over time or after therapy, and surgical risk (I.A.1–6).
- For lung volumes, DLCO, and exercise testing: document the specific clinical purpose (see policy I.B and I.C).
Document justification for post‑bronchodilator spirometry
For post‑bronchodilator spirometry, document in the record that bronchospasm signs/symptoms are present, baseline spirometry without bronchodilator is abnormal, or that reversibility/nonreversibility has not been demonstrated, as required by the policy.
- Policy I.A.7 requires at least one of: signs/symptoms consistent with bronchospasm; abnormal pre-bronchodilator spirometry; or reversibility has not been demonstrated.
- Repeat post-bronchodilator studies are covered only with documentation of clinically significant change.
Use ICD-10 codes from policy tables to support claims
When submitting claims, use applicable ICD-10 diagnosis codes from the policy's ICD-10 Tables that support medical necessity for the billed CPT code.
- Select ICD-10 codes from the appropriate table: Table 2 for CPTs 94617–94621 and Table 3 for CPT 94070, or other tables as mapped in the policy.
- Ensure diagnosis codes on claims match the documented clinical indication in the medical record.
Document the diagnosis using policy-listed ICD-10 codes
The policy provides extensive ICD-10 code lists that should be used to document medical necessity in the chart and on claims; include the diagnosis code that best supports the requested PFT.
- ICD-10 Table 1, Table 2, Table 3 and Table 4 contain diagnosis codes associated with specific CPT codes and indications.
- Choose the code from the policy lists that corresponds to the clinical indication for testing.
Include a supported ICD-10-CM diagnosis from the applicable table
Ensure the documented diagnosis is a supported ICD-10-CM code from the relevant ICD-10 table (Tables 1–4) in the policy that justifies medical necessity for the requested PFT CPT code(s).
Support medical necessity with criteria‑specific clinical documentation
Clinical documentation must support the specific policy criteria referenced in Section I, including documentation of presence/absence of dysfunction, severity, change over time, reversibility status, and any rationale for repeat testing.
- Follow Criteria I (I.A–I.E) when documenting medical necessity for the requested test.
- If repeat testing is requested, document clinically significant change per the Note under I.A.7.c or I.B.8 as applicable.
Follow CMS LCA A56717 and plan-specific billing guidance
Refer to CMS Local Coverage Article A56717 and other applicable Medicare NCDs/LCDs for billing and coding details; ensure adherence to Health Plan coverage documents and that state Medicaid provisions take precedence if they conflict with this policy.
- CMS LCA A56717 is cited for respiratory therapy billing/coding guidance (updated Oct 01, 2024).
- Review Medicare NCDs/LCDs as applicable and plan-specific coverage documents prior to billing.
Coding inclusion/exclusion does not guarantee coverage — verify coding guidance
Inclusion or exclusion of codes in the policy does not guarantee coverage; providers should consult up-to-date professional coding guidance and payer documents before submitting claims to reduce risk of denial.
- Policy notes that codes are informational and may be aligned with LCAs; verify current coding guidance.
- Coding additions/removals across revisions may affect coverage mappings—confirm current tables before billing.
Support CPTs 94617–94621 with ICD-10 Table 2 diagnosis codes
Claims for exercise and cardiopulmonary CPTs (94617, 94618, 94619, 94621) should be supported by an ICD-10-CM diagnosis from ICD-10 Table 2 as listed in the policy to substantiate medical necessity.
- Examples in Table 2 include E66.2 (morbid obesity with alveolar hypoventilation), R06.02 (shortness of breath), and other breathing symptom codes.
- Document the matching diagnosis in the medical record and on the claim.
Support CPT 94070 with ICD-10 Table 3 diagnosis codes
Claims for CPT 94070 (bronchospasm provocation) should be supported by one of the ICD-10-CM diagnosis codes listed in ICD-10 Table 3 in the policy.
- Table 3 examples include J44.9 (COPD), multiple J45.x asthma codes, and cough-related codes R05.x.
- Ensure the selected diagnosis reflects the clinical indication for provocation testing.
Risk of denial if CPT and diagnosis coding do not match policy tables
Claims may be denied if billed diagnosis codes are not within the policy's ICD-10 Tables or if CPT codes are not aligned with the policy's ICD-10 table mappings; coding mismatches and recent table additions/removals can affect coverage.
- Policy revisions have added and removed ICD-10 codes across tables—confirm the current tables before billing.
- A mismatch between CPT and the policy‑listed ICD-10 table is a denial risk.
Denial risk due to plan contracts, exclusions, or coverage limits
Coverage decisions are subject to the Health Plan's terms, conditions, exclusions and limitations; services may be denied based on plan contracts or coverage documents even if policy criteria appear met.
- State Medicaid provisions take precedence when conflicts exist between this policy and state Medicaid rules.
- The Health Plan retains the right to change, amend or withdraw this clinical policy.
Background and Rationale
Pulmonary function tests measure multiple aspects of respiratory physiology — including lung volumes, airflow, diffusion capacity (DLCO), and respiratory muscle/ventilatory performance — to evaluate symptoms such as cough, wheeze and dyspnea, assess disease severity or progression, determine response to therapy, and assist with preoperative risk assessment. Common PFTs described in the policy include spirometry (with or without bronchodilator), lung volumes (e.g., plethysmography), DLCO, lung compliance testing when other PFTs are equivocal, and exercise-related pulmonary studies such as the six-minute walk or other exercise protocols.[3]
Definitions and Test Descriptions
Additional Coding & Test Notes
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