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Clinical Policy Title: Pulmonary functions tests
Clinical Policy Number: 07.01.07
Effective Date: July 1, 2017
Initial Review Date: June 22, 2017
Most Recent Review Date: June 5, 2018
Next Review Date: June 2019
Related policies:
CP# 07.01.04 Exhaled nitric oxide for diagnosis of lung disease
CP# 07.02.07 Lung transplants
ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’ clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment.
For this policy, pulmonary function tests are defined as the noninvasive measurement of inhaled and
exhaled lung volume, total lung capacity, rates of air flow, and gas exchange.
Coverage policy
AmeriHealth Caritas considers the use of pulmonary function tests to be clinically proven and, therefore,
medically necessary when all of the following criteria are met (Csikesz, 2014; Global Initiative for Chronic
Obstructive Lung Disease, 2017; Miller, 2005):
A pulmonary diagnosis or evaluation cannot be made clinically, or test results are necessary
to manage the member’s clinical course.
The test information is needed to determine any of the following:
- The presence of lung disease or abnormal lung function.
- The type of abnormality.
- The extent of abnormality.
- The extent of disability due to abnormal lung function.
Policy contains:
Spirometry.
Pulmonary function tests.
Asthma.
Chronic obstructive pulmonary
disease.
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- One or more courses of therapy in the treatment of the particular condition.
The test is ordered by a treating physician and used in the member’s care.
The member is able to perform acceptable and reproducible maneuvers.
AmeriHealth Caritas considers the use of spirometry that measures volume and air flow on inhalation
and exhalation to be clinically proven and, therefore, medically necessary for the following indications
(National Institute for Health and Care Excellence, 2016; Meyer, 2016; Global Initiative for Chronic
Obstructive Lung Disease, 2010):
To evaluate abnormal symptoms or signs suggestive of pulmonary disease.
To measure the effect of systemic disease on pulmonary function (e.g., neuromuscular
disease and connective tissue disease).
To assess preoperative risk in members undergoing thoracic surgery, or members
undergoing major or complex surgery with known or suspected pulmonary disease.
To assess prognosis in lung transplant recipients.
To assess therapeutic effectiveness of bronchodilator therapy.
To monitor for adverse reactions to drugs with known pulmonary toxicity.
To assess reversibility of bronchospasm when signs or symptoms are consistent with
bronchospasm or pre-bronchodilator spirometry is abnormal.
- If reversibility of bronchospasm has been ruled out or demonstrated, repeat pre-
and post-bronchodilator study is medically necessary only when there is a significant
clinical change in the patient’s functional respiratory status requiring a change in
bronchoactive medications, and this is documented in the patient’s medical record.
AmeriHealth Caritas considers the use of spirometry for screening for asymptomatic patients with or
without a high risk of lung disease (e.g., prolonged smoking history) to be investigational and, therefore,
not medically necessary.
Limitations:
All other uses of pulmonary function tests are not medically necessary including, but not limited to:
When a diagnosis or evaluation can be made clinically or when test results are not necessary
to manage the patient’s disease.
Routine use at each office visit when physical exam and medical interview confirm either
the member’s claim of being stable or no clinically meaningful changes in pulmonary status.
As part of an epidemiological survey.
Peak flow meters (handheld spirometry) when used for diagnosing pulmonary disease.
Complete (or full) pulmonary function tests that incorporate body plethysmography, diffusion capacity,
bronchoprovocation, and other age-appropriate maneuvers should be reserved for more complex cases
to further quantify impairment and inform care management, particularly when there are
inconsistencies between history, physical features, and spirometry.
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For the purpose of medical review, the provider must use the various PFT modalities in a
purposeful and logical sequence in test selection.
Contraindications:
Pulmonary function tests can be physically demanding maneuvers and should be used
cautiously in patients with medical conditions that could be adversely affected by an
increase in: intrathoracic, intra-abdominal, and intracranial pressures; myocardial demand;
venous return; systemic blood pressure; chest wall and lung expansion; and risk for active
communicable diseases.
Patients should not be tested within one month of a myocardial infarction.
Quality assurance considerations:
Pulmonary function tests are medically necessary for members who are able to perform
acceptable and reproducible maneuvers. For young children with chronic lung disease or
recurrent wheeze, pulmonary function tests tailored to the specific disease can be
considered on a case-by-case basis.
Spirometry studies, in particular, require a minimum of three attempts that must meet
minimum acceptability criteria (Miller, 2005).
Personnel who perform all pulmonary function tests should have verifiable training in all
aspects of spirometry, lung volume, diffusion capacity, gas exchange, and pulmonary
exercise testing, including equipment operation, quality control, and test outcomes relative
to diagnosis and medical history.
Alternative covered services:
Physical examination and medical history.
Background
Pulmonary disease can affect the airways (large and small), lung parenchyma, pulmonary vasculature,
and the respiratory muscles. In 2014, the third-leading cause of death in the United States was chronic
lower respiratory disease comprising asthma and chronic obstructive pulmonary disease (chronic
obstructive pulmonary disease; emphysema and bronchitis; death rates from chronic lower respiratory
diseases were highest among older persons, white males and females, and blacks/African Americans
(Kochanek, 2016).
Accurate diagnosis of acute and chronic lung diseases can be challenging to achieve, particularly in
primary care, because medical history and physical examination are not reliable for the differential
diagnoses or estimating disease severity (José, 2014; Donner, 2011). Misdiagnosis of asthma may be as
high as 30 percent, and early diagnosis of chronic obstructive pulmonary disease is inadequately
addressed in many settings (Chung, 2014; Donner, 2011). Inappropriate interpretation of symptoms,
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unawareness of symptoms, underreporting of symptoms, and inadequate standards of care have been
implicated (Csikesz, 2014). Objective testing has become essential to appropriately characterize and
manage acute and chronic lung disease.
Assessment of pulmonary physiology involves measurement of pulmonary mechanics (airflows and lung
volumes), the ventilation-perfusion interrelationship, diffusion and gas exchange, and respiratory
muscle strength using maneuvers to measure and record the properties of these lung components.
Pulmonary function tests represent a battery of tests used to diagnose, stage, and monitor various
pulmonary diseases (National Heart, Lung, and Blood Institute [NHLBI], 2015). They include spirometry,
lung volume measurement, diffusing capacity for carbon monoxide, arterial blood gases, and exercise
testing. Radiography, skin testing, and certain biomarkers such as the fraction of exhaled nitric oxide
may be used in diagnosing lung disease (Csikesz, 2014).
Spirometry:
Spirometry is the most reproducible and readily available lung function test and is the primary focus of
this policy. It is an effort-dependent maneuver in which a seated (or sometimes standing) patient inhales
maximally into a mouthpiece from tidal breathing to total lung capacity and then rapidly exhales to the
fullest extent until no further volume is exhaled. A spirometer measures either displaced volume or
airflow by a flow-sensing device, such as a pneumotachometer, that mathematically derives volume. It is
simple and easy to perform, unlike other pulmonary function tests that are more time-consuming and
require specialized equipment and training. Instrumentation for spirometry can be portable, hand-held,
or stationary.
The three most commonly used spirometric values are forced vital capacity (FVC), forced expired volume
in one second (FEV1), and the FEV1/FVC ratio, but spirometry can provide other important measures of
pulmonary mechanics (Miller, 2005):
FEV1 — the maximal volume of air exhaled in the first second of a forced expiration from a
position of full inspiration; a sensitive indicator of larger airway disease.
FVC — the maximal volume of air exhaled with maximally forced effort from a maximal
inspiration. FEV at two seconds (FEV2) and FEV at three seconds (FEV3) may approximate
FVC in young children, and FEV at six seconds (FEV6) may approximate FVC.
Expiratory vital capacity (EVC) — the maximal volume of air exhaled from the point of
maximal inhalation.
FEF25–75 — the mean forced expiratory flow between 25 percent and 75 percent of the FVC;
an indicator of small airway disease.
FEV1/FVC — an indicator of airway obstruction if the value is less than 70 percent (Global
Initiative for Chronic Obstructive Lung Disease, 2010). An alternative measure, the
FEV1/FEV6, has been proposed.
Inspiratory capacity (IC) — the volume change recorded when taking a slow full inspiration
with no hesitation from a position of passive end-tidal expiration. IC is an indirect estimate
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of the degree of lung hyperinflation at rest, and is useful to assess changes in FRC with
pharmacological treatment.
Inspiratory VC — the maximal volume of air inhaled from the point of maximal exhalation,
achieved by a slow expiration from end-tidal inspiration.
Maximum voluntary ventilation (MVV) — the maximum volume of air a subject can breathe
over a specified period of time (12 seconds for normal subjects); largely superseded by FEV1.
Peak flow — the maximum expiratory flow achieved from a maximum forced expiration,
starting without hesitation from the point of maximal lung inflation; useful for assessing
flow rate patterns, hence airway integrity, over time.
Vital capacity (VC) — the volume represented from the position of full inspiration to
complete expiration (unforced).
Spirometry can be administered in the ambulatory, office, emergency room, and inpatient settings. It
can be performed without a bronchodilator for screening purposes or before-and-after a bronchodilator
for diagnostic purposes. Practitioners and patients may use hand-held peak expiratory flow (PEF or peak
flow) meters to monitor trends in air flow. Accurate interpretation of results requires maximal patient
effort and well-defined acceptability and reproducibility standards (Miller, 2005). Normative values are
derived from population studies of healthy subjects with similar age, race, weight, and height to which
measured values are compared to approximate disease severity.
Searches
AmeriHealth Caritas searched PubMed and the databases of:
UK National Health Services Centre for Reviews and Dissemination.
Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other
evidence-based practice centers.
The Centers for Medicare & Medicaid Services (CMS).
We conducted searches on April 25, 2018. Search terms were: “Pulmonary Disease, Chronic
Obstructive” (MeSH), “Mass Screening” (MeSH), “Respiratory Function Tests” (MeSH), “Spirometry”
(MeSH), “Forced Expiratory Volume” (MeSH), “Forced Expiratory Flow Rates” (MeSH), “Vital Capacity”
(MeSH), “Ambulatory Care” (MeSH), “Outpatient Clinics, Hospital” (MeSH), and “Outpatients” (MeSH).
We included:
Systematic reviews, which pool results from multiple studies to achieve larger sample sizes
and greater precision of effect estimation than in smaller primary studies. Systematic
reviews use predetermined transparent methods to minimize bias, effectively treating the
review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.
Guidelines based on systematic reviews.
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Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple
cost studies), reporting both costs and outcomes — sometimes referred to as efficiency
studies — which also rank near the top of evidence hierarchies.
Findings
We identified two systematic reviews and 11 evidence-based practice guidelines for this policy. Medical
history and physical examination are essential but often inadequate means of excluding diagnoses or
characterizing the status of lung impairment, and symptoms often do not correlate with objective
assessment. Quantitative measures of lung function are standard of care for persons with acute or
chronic lung disease. Spirometry is the most frequently used PFT. It is an accurate, available,
noninvasive, safe, and relatively inexpensive first-line test for evaluating lung function.
As a diagnostic test, the evidence supports spirometry when medical history and physical examination
are inadequate to inform care, and quantitative information is necessary to (National Institute for
Health and Care Excellence, 2016; Meyer, 2016; Global Initiative for Chronic Obstructive Lung Disease,
2010):
Determine the presence, type, and severity of obstructive, restrictive, and combined
obstructive/restrictive lung defects.
Confirm a diagnosis.
Measure therapeutic response.
Assess preoperative risk in persons undergoing thoracic surgery or undergoing major or
complex surgery with known or suspected pulmonary disease.
Monitor allograft status before and after lung transplantation.
Other findings include:
Peak flow meters should be used to monitor changes in flow rates, but not to diagnose
pulmonary disease (Chung, 2014).
The value of spirometry in children younger than 6 years of age is less clear (Kang, 2016;
Lahiri, 2016; Rosenfeld, 2013). Spirometry can identify pulmonary exacerbations and
monitor treatment response in those children able to perform acceptable and reproducible
maneuvers. The evidence argues against routine use in diagnostic evaluation and clinical
monitoring of infants and very young children with cystic fibrosis, bronchopulmonary
dysplasia, or recurrent wheeze, but pulmonary function tests tailored to the specific disease
in this population can be considered on a case-by-case basis.
Complete or full pulmonary function tests that incorporate body plethysmography, diffusion
capacity, arterial blood gases, and other age-appropriate pulmonary function tests should
be reserved for more complex cases to further quantify impairment and inform care
management, particularly when there are inconsistencies between history, physical
features, and spirometry (Chung, 2014).
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Potential risks associated with pulmonary function tests relate to the physiologic effects and anatomical
demand that forced maneuvers can inflict on intrathoracic, intra-abdominal, and intracranial pressures;
myocardial demand; venous return; systemic blood pressure; and chest wall and lung expansion. There
is also an increased risk in acquiring active communicable diseases. Most contraindications to pulmonary
function tests are relative and require a delay in performing them until the issues resolve, as opposed to
outright avoidance.
Despite reports of underdiagnosis of chronic obstructive pulmonary disease and misdiagnosis of asthma,
spirometry as a screening test (often referred to as pre-bronchodilator spirometry) in asymptomatic
populations remains controversial. Screening comprises validated questionnaires, spirometry, or both.
The rationale for more intensive case-finding in asymptomatic populations using spirometry is to
identify lung disease at an earlier stage when treatment and prevention strategies can affect health
outcomes. While there is a need to improve early and accurate diagnosis of various lung conditions,
current evidence does not support a health, treatment, or smoking cessation benefit in screen-detected
populations (Guirguis-Blake, 2016). Multiple evidence-based guidelines do not support screening
spirometry in the absence of symptoms (Coates, 2013; Global Initiative for Chronic Obstructive Lung
Disease, 2010; Qaseem, 2011; U.S. Preventive Services Task Force, 2016).
As the use of spirometry increases, principally in office-based settings, access to quality spirometry is a
major concern. The results must be interpreted carefully as all lung function tests are effort dependent.
The American Thoracic Society, the European Respiratory Society, and Global Initiative for Chronic
Obstructive Lung Disease have developed clinical practice and quality assurance guidelines for
pulmonary function tests to improve testing quality and interpretation (Miller, 2005; Global Initiative for
Chronic Obstructive Lung Disease, 2017). Pulmonary function tests should be performed and interpreted
by providers with demonstrated proficiency in test performance and interpretation.
Policy updates:
We did not identify any recently published guidelines/other or peer-reviewed publications in 2018.
Summary of clinical evidence:
Citation Content, Methods, Recommendations
Global Initiative for Chronic
Obstructive Lung Disease
(2017)
Guideline: From the Global
Strategy for the Diagnosis,
Management and
Prevention of chronic
obstructive pulmonary
disease
Key points:
The role of screening at-risk populations in primary care is more controversial.
Whether early detection in relatively asymptomatic smokers significantly increases
tobacco cessation rates is unclear.
The most cost-effective method would appear to be a case-finding technique and
performing spirometry in those at risk of chronic obstructive pulmonary disease.
Clinicians should suspect chronic obstructive pulmonary disease and perform
spirometry when indicators are present in an individual aged over 40 years: chronic
cough or sputum production, dyspnea, and/or history of exposure to risk factors (e.g.,
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Citation Content, Methods, Recommendations
tobacco smoke, occupational dusts, home cooking, and biomass fuels).
Guirguis-Blake (2016) for
AHRQ
Screening for chronic
obstructive pulmonary
disease
Key points:
Systematic review of diagnostic accuracy: five studies (n=3,048) of three externally
validated chronic obstructive pulmonary disease questionnaires; two studies of pre-
bronchodilator PF; two studies of pre-bronchodilator microspirometry FEV1/FEV6; one
study of post-bronchodilator microspirometry FEV1/FEV6; one study of a staged
approach incorporating both the chronic obstructive pulmonary disease Diagnostic
Questionnaire and FEV1/FEV6 tests; five randomized controlled trials (RCTs) (n=1,620)
of the effectiveness of chronic obstructive pulmonary disease screening in influencing
smoking cessation rates; and 14 treatment RCTs in screen-detected patients.
Overall quality: low to moderate. High risk of bias, incomplete reporting of study design
elements and harms.
Insufficient evidence to support that systematic screening for chronic obstructive
pulmonary disease in primary care improves health outcomes, or offers a treatment or
smoking cessation benefit in screen-detected populations.
Kang (2016) for the
American Academy of
Neurology and the American
Association of
Neuromuscular &
Electrodiagnostic Medicine
Guideline: Evaluation,
diagnosis, and management
of congenital muscular
dystrophy (CMD)
Key points:
Physicians should monitor pulmonary function tests such as spirometry and oxygen
saturation in the awake and sleep states of patients with CMD, with monitoring levels
individualized on the basis of the child’s clinical status (Level B).
Lahiri (2016)
Guideline: From the CF
Foundation for Preschoolers
With CF
Key points:
For children with CF, ages 2 to 5 years, spirometry should be attempted as early as age
3 years, depending on the developmental stage of the individual child (Consensus
recommendation).
For children with CF, ages 3 years and older, use spirometry to identify pulmonary
exacerbations and monitor treatment response in those children able to perform
acceptable and reproducible maneuvers (Consensus recommendation).
National Institute for Health
and Care Excellence (2016)
Guideline: Routine preoperative tests for elective surgery
Key points:
Routine pulmonary function tests and arterial blood gas analysis before surgery are not
recommended, based on low or very-low-quality evidence suggesting that test may
provide reassurance both to the patients and clinician before surgery, but had no real
impact on perioperative or general clinical management.
- Exception: Thoracic surgery or those with respiratory problems undergoing
major or complex surgery.
Spirometry alone is sufficient for guiding perioperative management in most patients.
Pulmonary function tests may have a role in optimizing the patient before surgery under
the advice of an anesthetist, leading to better postoperative management.
There is uncertainty about which patients with known or suspected respiratory disease
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Citation Content, Methods, Recommendations
require preoperative lung function tests, what time period prior to surgery these are
required, and whether spirometry or more sophisticated tests are indicated.
Skloot (2016) for the ATS
Guideline: Asthma in the
elderly
Key points:
Spirometry and airway reactivity measurements are first-line methods for diagnosing
and monitoring asthma in the elderly.
Age-adjusted values are essential for interpretation to avoid overdiagnosing respiratory
impairment.
Normative data for nonwhite individuals and for those older than 75 years are sparse.
USPSTF (2016)
Guideline: Screening for
chronic obstructive
pulmonary disease
Key points:
“D” recommendation against screening for chronic obstructive pulmonary disease in
asymptomatic adults based on the conclusion that screening for chronic obstructive
pulmonary disease had no net benefit and large associated opportunity costs.
Inadequate evidence to conclude on the harms of screening, improvement in health
outcomes, improvement in smoking cessation, or alterations in disease course;
opportunity costs may be large, and resources needed to screen using spirometry with
or without questionnaires can be substantial (Guirguis-Blake, 2016).
Haroon (2015)
Effectiveness of case-finding
strategies for chronic
obstructive pulmonary
disease in primary care
Key points:
Systematic review and meta-analysis of three RCTs, one controlled trial, and 35
uncontrolled studies that included pre-screening with questionnaires (n=13), handheld
flow meters (n=5), or direct invitation to diagnostic spirometry (n=30).
Overall quality: low. Heterogeneous studies, lack of comparison groups, inadequate
reporting, and diversity in the definition of chronic obstructive pulmonary disease.
Any approach identified more undiagnosed chronic obstructive pulmonary disease
versus usual care; targeting those at higher risk (e.g., smokers) and pre-screening (e.g.,
using questionnaires) is likely to increase the yield, but impact on clinical care and
patient outcomes is unknown.
Well-conducted RCTs are needed.
Chung (2014) for the
ERS/ATS
Guideline: Definition,
evaluation and treatment of
severe asthma
Key points:
Spirometry with both inspiratory and expiratory loops, following pre- and post-
bronchodilator administration, should be obtained to confirm reversible airflow limitation.
Further testing with complete pulmonary function tests, including diffusing capacity and
bronchoprovocation testing, in the case of relatively preserved lung function can be
considered on a case-by-case basis, particularly when there are inconsistencies
between history, physical features, and spirometry.
Meyer (2014) for the
International Society for
Heart and Lung
Transplantation, ATS, and
ERS
Guideline: Diagnosis and
management of bronchiolitis
obliterans syndrome (BOS)
Key points:
In most transplant centers, lung transplant recipients (including asymptomatic patients)
receive sustained follow-up including routine clinical evaluation, spirometry (both in the
clinic and in remote in-home settings), and other methods for monitoring allograft status
(such as fiber-optic bronchoscopy, as appropriate).
Such monitoring is generally sustained beyond the first 6–12 months following
transplantation.
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Citation Content, Methods, Recommendations
in lung transplantation
recipients
Coates (2013) for the
Canadian Thoracic Society
Guideline: Spirometry in
primary care
Key points:
Based on the joint ATS/ERS standards for pulmonary function tests (Miller, 2005).
Potential risks associated with spirometry and other forced expiratory maneuvers relate
to increased intrathoracic, intra-abdominal, and intracranial pressures; myocardial
demand; venous return; systemic blood pressure; chest wall and lung expansion; and
active communicable diseases. This calls for prudence in patients with medical
conditions that could be adversely affected by these physiological consequences.
Rosenfeld (2013) for the
ATS
Guideline: Optimal lung
function tests for monitoring
CF, BPD, and recurrent
wheezing in children less
than 6 years of age
Key points:
Recommendations covered infant pulmonary function testing (raised-volume rapid
thoracic compression and plethysmography); preschool spirometry; specific airway
resistance; the interrupter technique; the forced oscillation technique; and multiple-
breath washout.
All tests are safe and feasible; sedated infant lung function testing requires extensive
training; unclear impact of testing on patient outcomes.
Reference data are predominantly from non-Hispanic white children, device- and
technique-dependent, and derived from low-quality data.
Insufficient evidence to support routine use in diagnostic evaluation and clinical
monitoring of infants and young children with CF, BPD, or recurrent wheeze; may be
valuable for specific concerns (e.g., ongoing symptoms or treatment monitoring), and as
outcome measures in clinical research studies.
Qaseem (2011) for the ACP,
ACCP, ATS, and ERS
Guideline: Diagnosis and
Management of Stable
chronic obstructive
pulmonary disease
Key points:
Spirometry should be obtained to diagnose airflow obstruction in patients with
respiratory symptoms (grade: strong recommendation, moderate-quality evidence).
Spirometry should not be used to screen for airflow obstruction in individuals without
respiratory symptoms (grade: strong recommendation, moderate-quality evidence).
National Asthma Education
and Prevention Program -
Expert Panel Report 3
(2007)
Guideline: Diagnosis and
management of asthma
Key points:
Recommends spirometry to demonstrate obstruction and assess reversibility, including
in children ≥5 years of age using a short-acting bronchodilator.
Recommends considering spirometry to establish a diagnosis of asthma if any of these
indicators is present:
- Wheezing, history of cough (particularly at night), recurrent wheezing,
dyspnea, or chest tightness.
- Symptoms occur or worsen in the presence of exogenous factors (infection,
exposure to allergens, airborne particles, changes in weather), strong
emotional expression, and menstrual cycles.
- Symptoms occur or worsen at night, awakening the patient.
Office-based physicians who care for asthma patients should have access to spirometry
for diagnosis and periodic monitoring using equipment and techniques that meet ATS
standards.
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References
Professional society guidelines/other:
Chronic Obstructive Pulmonary Disease: Screening. Release date: April 2016. U.S. Preventive Services
Task Force (USPSTF) website.
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chronic-
obstructive-pulmonary-disease-screening. Accessed April 25, 2018.
Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation and
treatment of severe asthma. Eur Respir J. 2014; 43(2): 343 – 373.
Coates AL, Graham BL, McFadden RG, et al. Spirometry in primary care. Can Respir J. 2013; 20(1): 13 –
21.
From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for
Chronic Obstructive Lung Disease (GOLD) 2017. GOLD website. http://goldcopd.org. Accessed April 25,
2018.
Kang PB, Morrison L, Iannaccone ST, et al. Evidence-based guideline summary: evaluation, diagnosis, and
management of congenital muscular dystrophy: Report of the Guideline Development Subcommittee of
the American Academy of Neurology and the Practice Issues Review Panel of the American Association
of Neuromuscular & Electrodiagnostic Medicine. Neurology. 2015; 84(13): 1369 – 1378.
Lahiri T, Hempstead SE, Brady C, et al. Clinical Practice Guidelines from the Cystic Fibrosis Foundation for
Preschoolers with Cystic Fibrosis. Pediatrics. 2016; 137(4).
Meyer KC, Raghu G, Verleden GM, et al. An international ISHLT/ATS/ERS clinical practice guideline:
diagnosis and management of bronchiolitis obliterans syndrome. Eur Respir J. 2014; 44(6): 1479 – 1503.
Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J. 2005; 26(2): 319 –
338.
National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis
and Management of Asthma. Full Report 2007. National Heart, Lung, and Blood Institute website.
https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf. Accessed April 25, 2018.
Preoperative tests (update). Routine preoperative tests for elective surgery. National Institute for Health
and Care Excellence (NICE) website. https://www.nice.org.uk/guidance/ng45/evidence/full-guideline-
87258149468. Accessed April 25, 2018.
12
Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive
pulmonary disease: a clinical practice guideline update from the American College of Physicians,
American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann
Intern Med. 2011; 155(3): 179 – 191.
Rosenfeld M, Allen J, Arets BH, et al. An official American Thoracic Society workshop report: optimal
lung function tests for monitoring cystic fibrosis, bronchopulmonary dysplasia, and recurrent wheezing
in children less than 6 years of age. Ann Am Thorac Soc. 2013; 10(2): S1 – s11.
Peer-reviewed references:
Csikesz NG, Gartman EJ. New developments in the assessment of COPD: early diagnosis is key. Int J
Chron Obstruct Pulmon Dis. 2014; 9: 277 – 286.
Donner CF, Virchow JC, Lusuardi M. Pharmacoeconomics in COPD and inappropriateness of diagnostics,
management and treatment. Respir Med. 2011; 105(6): 828 – 837.
Haroon SM, Jordan RE, O'Beirne-Elliman J, Adab P. Effectiveness of case finding strategies for COPD in
primary care: a systematic review and meta-analysis. NPJ Prim Care Respir Med. 2015; 25: 15056.
José BP, Camargos PA, Cruz Filho AA, Correa Rde A. Diagnostic accuracy of respiratory diseases in
primary health units. Rev Assoc Med Bras (1992). 2014; 60(6): 599 – 612.
Kochanek KD, Murphy SL, Xu JQ, Tejada-Vera B. Deaths: Final data for 2014. National vital statistics
reports; vol 65 no 4. 2016. National Center for Health Statistics website.
https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf. Accessed April 25, 2018.
Pulmonary Function Tests. National Heart, Lung, and Blood Institute (NHLBI) website.
https://www.nhlbi.nih.gov/health/health-topics/topics/lft. Accessed April 25, 2018.
Screening for Chronic Obstructive Pulmonary Disease: A Systematic Evidence Review for the U.S.
Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality
(US); 2016 Apr. (Evidence Syntheses, No. 130). NCBI website.
https://www.ncbi.nlm.nih.gov/books/NBK361185/. Accessed April 25, 2018.
CMS National Coverage Determinations (NCDs):
No NCDs identified as of the writing of this policy.
Local Coverage Determinations (LCDs):
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L33707 Pulmonary Diagnostic Services. CMS website. http://www.cms.gov/medicare-coverage-
database/details/lcd-details.aspx?LCDId=33707&ver=12Accessed April 25, 2018.
L34247 Pulmonary Function Testing CMS website. http://www.cms.gov/medicare-coverage-
database/details/lcd-details.aspx?LCDId=34247&ver=22. Accessed April 25, 2018.
DL34247 Pulmonary Function Testing CMS website. http://www.cms.gov/medicare-coverage-
database/details/lcd-details.aspx?LCDId=37285&ver=5. Accessed April 25, 2018.
DL37289 Pulmonary Function Testing CMS website. http://www.cms.gov/medicare-coverage-
database/details/lcd-details.aspx?LCDId=37288&ver=4. Accessed April 25, 2018.
L35360 Pulmonary Function Testing CMS website. http://www.cms.gov/medicare-coverage-
database/details/lcd-details.aspx?LCDId=35360&ver=32. Accessed April 25, 2018.
InterQual
CP: Procedures. Electrophysiology (EP) testing +/- radiofrequency ablation (RFA), cardiac.
CP: Procedures Adult. Radiofrequency ablation (RFA), cardiac.
Commonly submitted codes
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is
not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and
bill accordingly.
CPT Code Description Comments
94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation
94011 Measurement of spirometric forced expiratory flows in an infant or child through 2 years of age
94012 Measurement of spirometric forced expiratory flows, before and after bronchodilator, in an infant or child through 2 years of age
94013 Measurement of lung volumes (ie, functional residual capacity [FRC], forced vital capacity [FVC], and expiratory reserve volume [ERV]) in an infant or child through 2 years of age
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 (eg, antigen[s], cold air, methacholine)
94150 Vital capacity, total (separate procedure)
94200 Maximum breathing capacity, maximal voluntary ventilation
94250 Expired gas collection, quantitative, single procedure (separate procedure)
94375 Respiratory flow volume loop
94400 Breathing response to CO2 (CO2 response curve)
14
CPT Code Description Comments
94450 Breathing response to hypoxia (hypoxia response curve)
94617 Exercise test for bronchospasm, including pre- and post-spirometry, electrocardiographic recording(s), and pulse oximetry
94618 Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed
94621 Pulmonary stress testing; complex (including measurements of CO2 production, O2 uptake, and electrocardiographic recordings)
94640
Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device
94664 Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device
94680 Oxygen uptake, expired gas analysis; rest and exercise, direct, simple
94681 Oxygen uptake, expired gas analysis; including CO2 output, percentage oxygen extracted
94690 Oxygen uptake, expired gas analysis; rest, indirect (separate procedure)
94726 Plethysmography for determination of lung volumes and, when performed, airway resistance
94727 Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes
94728 Airway resistance by impulse oscillometry
94729 Diffusing capacity (eg, carbon monoxide, membrane) (List separately in addition to code for primary procedure)
94750 Pulmonary compliance study (eg, plethysmography, volume and pressure measurements)
ICD-10 Code Description Comments
B44.81 Allergic bronchopulmonary aspergillosis
C33-C34.92 Malignant Neoplasm of trachea, unspecified part of left bronchus or lung
C78.00-C78.02 Secondary malignant neoplasm of unspecified lung - Secondary malignant
neoplasm of left lung
C78.30-C78.39 Secondary malignant neoplasm of unspecified respiratory organ - Secondary
malignant neoplasm of other respiratory organs
D14.12 Benign neoplasm of trachea
D14.30-D14.32 Benign neoplasm of unspecified bronchus and lung - Benign neoplasm of left
bronchus and lung
D57.01 Hb-SS disease with acute chest syndrome
D57.211 Sickle-cell/Hb-C disease with acute chest syndrome
D57.811 Sickle-cell thalassemia with acute chest syndrome
D86.0-D86.9 Sarcoidosis of lung
E84.0 Cystic fibrosis with pulmonary manifestations
E84.19 Cystic fibrosis with other intestinal manifestations
I26.01-I26.99 Septic pulmonary embolism with acute cor pulmonale
J17 Pneumonia in diseases classified elsewhere
J18.8-J18.9 Other pneumonia
J20.0-J21.9 Acute bronchitis
J22 Unspecified acute lower respiratory infection
J39.8 Other specified diseases of upper respiratory tract
15
ICD-10 Code Description Comments
J40 Bronchitis, not specified as acute or chronic
J41.0-J42 Simple chronic bronchitis
J43.0-J43.9 Emphysema
J44.0-J45.998 Chronic obstructive pulmonary disease with acute lower respiratory infection
J47.0-J47.9 Bronchiectasis with acute lower respiratory infection
J60 Coalworker's pneumoconiosis
J61 Pneumoconiosis due to asbestos and other mineral fibers
J62.0-J62.8 Pneumoconiosis due to talc dust - Pneumoconiosis due to other dust
containing silica
J63.0-J63.6 Aluminosis (of lung) - Pneumoconiosis due to other specified inorganic dusts
J64-J65 Unspecified pneumoconiosis
J66.0-J66.8 Airway disease due to other specific organic dusts
J67.0-J67.9 Farmer's lung - Hypersensitivity pneumonitis due to unspecified organic dust
J70.0-J70.9 Acute pulmonary manifestations due to radiation - Respiratory conditions due
to unspecified external agent
J80-J81.0 Acute respiratory distress syndrome, Pulmonary Edema
J82 Pulmonary eosinophilia, not elsewhere classified
J84.01 Alveolar proteinosis
J84.02 Pulmonary alveolar microlithiasis
J84.09 Other alveolar and parieto-alveolar conditions
J84.10 Pulmonary fibrosis, unspecified
J84.111-J84.117 Idiopathic interstitial pneumonia, not otherwise specified - Desquamative
interstitial pneumonia
J84.17 Other interstitial pulmonary diseases with fibrosis in diseases classified
elsewhere
J84.2 Lymphoid interstitial pneumonia
J84.81 Lymphangioleiomyomatosis
J84.82 Adult pulmonary Langerhans cell histiocytosis
J84.89 Other specified interstitial pulmonary diseases
J95.1-J95.3 Acute/Chronic pulmonary insufficiency following surgery
J95.821-J95.822 Acute/Acute and chronic postprocedural respiratory failure
J96.00-J96.92 Acute respiratory failure, unspecified
J98.01-J98.09 Acute bronchospasm, other diseases of bronchus, not specified
J98.11-J98.4 Atelectasis - Other disorders of lung
J98.6 Disorders of diaphragm
J98.8 Other specified respiratory disorders
J99 Respiratory disorders in diseases classified elsewhere
M31.0 Hypersensitivity angiitis
M32.13 Lung involvement in systemic lupus erythematosus
M33.01 Juvenile dermatomyositis with respiratory involvement
M33.11 Other dermatomyositis with respiratory involvement
M33.21 Polymyositis with respiratory involvement
M33.91 Dermatopolymyositis, unspecified with respiratory involvement
M34.81 Systemic sclerosis with lung involvement
M35.02 Sicca syndrome with lung involvement
R04.2 Hemoptysis
16
ICD-10 Code Description Comments
R04.89 Hemorrhage from other sites in respiratory passages
R04.9 Hemorrhage from respiratory passages, unspecified
R05 Cough
R06.00-R06.09 Dyspnea, unspecified
R06.2 Wheezing
R06.3 Periodic breathing
R06.81 Apnea, not elsewhere classified
R06.82 Tachypnea, not elsewhere classified
R06.83-R06.89 Snoring, Other abnormalities of breathing
R09.2 Respiratory arrest
R91.1-R91.8 pulmonary nodule - Other nonspecific abnormal finding of lung field
Z01.81 Encounter for preprocedural respiratory examination
HCPCS
Level II Code Description Comments
N/A Not Applicable
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