Pulmonology & Sleep Medicine Billing Audit
Make sure PFTs, sleep studies and bronchoscopies are coded without bundling errors and meet the coverage criteria payers check.
Pulmonary and sleep practices bill many diagnostic tests with overlapping codes. Spirometry (94010) is included in spirometry before and after a bronchodilator (94060), lung volumes and diffusing capacity have their own codes, and billing overlapping PFT components together is a common source of denials and refunds. Sleep testing depends on coverage criteria: many payers require a home sleep apnea test for suspected uncomplicated obstructive sleep apnea before they will pay for in-lab polysomnography, unless the record shows why a home test is not appropriate. Bronchoscopy claims need each separately reportable service — lavage, biopsies, EBUS — documented. Our audit reviews test reports, sleep study orders and procedure notes against claims and payer policies.
Audit red flags
- Spirometry (94010) billed on the same date as spirometry before and after bronchodilator (94060).
- In-lab sleep studies billed without documenting why a home sleep apnea test was not appropriate, where the payer requires it.
- PAP follow-up for Medicare patients missing the adherence data and re-evaluation needed for continued equipment coverage.
- Bronchoscopy add-on services billed without procedure-note detail on the sites sampled or segments lavaged.
Audit action plan
- 1. Test-Level Bundling Review — Check PFT and sleep-study claims for overlapping codes billed on the same date and for missing interpretations.
- 2. Coverage Criteria Audit — Compare sleep study orders and documentation with each payer's policy for home versus in-lab testing and titration studies.
- 3. Procedure Note Review — Audit bronchoscopy claims against procedure notes for separately reportable services and correct add-on units.
Codes reviewed
- 94010 / 94060 — Spirometry / spirometry before and after bronchodilator
- 94726 / 94729 — Plethysmography for lung volumes / diffusing capacity add-on
- 95810 / 95806 / G0399 — In-lab polysomnography / home sleep apnea testing
- 31622–31654 — Bronchoscopy, diagnostic and surgical (lavage, biopsies, EBUS)
Frequently asked questions
Can spirometry and pre/post-bronchodilator spirometry be billed together?
No. 94060 includes the spirometry described by 94010, so only 94060 is billed when a bronchodilator response is tested on the same date.
When will payers cover an in-lab sleep study instead of a home test?
Many payers require a home sleep apnea test first for suspected uncomplicated obstructive sleep apnea, and cover in-lab polysomnography when the record documents a reason — such as significant heart or lung disease, a suspected sleep disorder other than obstructive apnea, or a prior home test that was not diagnostic. Each payer publishes its own criteria.
What does Medicare require for continued CPAP coverage?
Medicare requires documented adherence — use for at least four hours per night on 70% of nights during a consecutive 30-day period within the first three months — and a face-to-face re-evaluation with the treating practitioner between day 31 and day 91 of therapy.