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Duplicate Billing of Services: Pulmonary Diagnostic Procedures (CPT 94010 – 94799) and Evaluation and Management Codes (99211-99213)

Cahaba GBA performed data analysis of claims billed with Pulmonary Diagnostic Procedures (CPT 94010 – 94799) and Evaluation and Management services (CPT 99211-99213).  According to the data analysis, overpayments are associated with evaluation and management services (99211-99213) billed without modifier 25 on the same date of service as a pulmonary diagnostic procedure.  If a physician in attendance for a pulmonary function study obtains a history and performs a physical related to the pulmonary function testing, separate reporting of an evaluation and management service is not appropriate.  If a significant, separately identifiable E&M service is performed unrelated to the performance of the pulmonary function test, an E&M service may be reported with modifier 25.  Cahaba’s data revealed that there is no provider specific issue but a widespread issue based on data from Jan-May 2013 dates of service.  There was $337,814 paid for E&M codes billed without modifier 25 during this time period. 

Cahaba GBA requests providers review their billing of these codes and make any necessary corrections.