Do you have any general tips regarding correct documentation for pulmonary function studies?
Medical record documentation should clearly indicate the medical necessity for performing the services. The medical necessity should be documented by ancillary clinical staff (the signs and symptoms) as well as by the physician. The ICD-10-CM diagnosis codes submitted on the claim must be supported by the medical record documentation. All providers of pulmonary function tests should have on file a referral (a prescription) with clinical diagnoses and requested tests. Indications for the studies should be clearly described in the clinical records and available for review. All equipment and studies should meet the minimum standards outlined by the American Thoracic Society (https://www.thoracic.org). Spirometry studies, in particular, require a minimum of three attempts that must meet minimum acceptability criteria. All studies require an interpretation, with a written report. Computerized reports must have a physician’s signature, attesting to their accuracy. Documentation should support that the test results and interpretation were used for the treatment of a specific medical problem.
This question was answered in our Coding Essentials for RT/Pulmonary Function. For more hot topics relating to respiratory services, please visit our store or call us at 1.800.252.1578, ext. 2.