Pulmonology Medical Billing & Credentialing Services

Pulmonology billing requires specialized expertise in complex respiratory procedure coding, diagnostic testing interpretation, and strict documentation standards that general medical billing services cannot adequately address. Pulmonology practices including solo pulmonologists, sleep medicine specialists, critical care providers, and interventional pulmonology teams face unique revenue cycle challenges such as frequent claim denials, evolving quality payment program requirements, varying payer policies regarding pulmonary function testing medical necessity, and intricate modifier applications affecting reimbursement sustainability. Pro Health Care Advisors delivers comprehensive pulmonology billing solutions designed for small to mid-sized respiratory care practices seeking accurate claims processing, reduced denial rates, improved cash flow, and expert guidance navigating the evolving regulatory landscape governing pulmonary diagnostic and therapeutic services reimbursement.

Understanding Pulmonology Billing Complexities

Pulmonology billing differs substantially from other medical specialties due to hundreds of procedure-specific CPT codes spanning diagnostic testing and interventional procedures, bundling rules affecting same-day services, and documentation standards that directly determine reimbursement approval or denial. Pulmonary function tests including spirometry coded 94010, pre and post-bronchodilator studies using 94060, and diffusing capacity testing 94720 require precise technical component documentation, proper physician interpretation reporting, and medical necessity justification supporting testing orders.

CMS finalized new Pulmonology MIPS Value Pathway requirements in 2025 focusing on quality measures for COPD, asthma, and sleep apnea management requiring documentation beyond procedural coding. Pro Health Care Advisors implements systematic quality assurance protocols identifying documentation gaps including incomplete spirometry interpretation reports, missing medical necessity for repeat testing, absent modifier applications for bilateral procedures, and insufficient quality measure documentation before claim submission, preventing costly denials and audit vulnerabilities.

Comprehensive Billing Services for Pulmonology Providers

Expert Coding for Pulmonary Function Testing

Our specialists ensure accurate code selection for spirometry testing using 94010 for basic spirometry, 94060 for pre and post-bronchodilator studies, diffusing capacity coded 94720, lung volume measurements using 94726-94727, and flow volume loops 94375 requiring proper component modifier application.

Bronchoscopy Procedure Billing with Multiple Endoscopy Rules

Bronchoscopy billing demands precise code selection for diagnostic bronchoscopy 31622, bronchoalveolar lavage coded 31624, transbronchial biopsy using 31628, endobronchial ultrasound 31652-31653, and understanding multiple endoscopy payment rules where primary procedures receive full reimbursement while additional procedures paid at reduced rates.

Sleep Study and Home Sleep Testing Claims Processing

Pro Health Care Advisors manages sleep medicine billing including polysomnography codes 95810-95811 for attended sleep studies, home sleep apnea testing using 95800-95801, CPAP titration studies coded 95811, and proper documentation supporting split-night study medical necessity.

Critical Care and Mechanical Ventilation Billing

Critical care provided by pulmonologists requires time-based coding using 99291-99292 with detailed documentation excluding separately billable procedures, while mechanical ventilation management codes 94002-94005 demand daily documentation supporting ventilator parameter adjustments and weaning protocols.​

Strategic Denial Management Reducing Revenue Loss

Pulmonology practices experience substantially higher denial rates than many specialties due to insufficient medical necessity documentation for pulmonary function testing, bundling violations billing multiple bronchoscopy procedures inappropriately, missing prior authorizations for interventional procedures, and incomplete interpretation reports lacking required elements. Common denial triggers include spirometry tests billed without supporting clinical indicators justifying testing frequency, bronchoscopy procedures exceeding payer coverage limitations, same-day evaluation and management services denied as bundled with procedures, and claims submitted without proper component modifier application.

Our denial management system tracks patterns specific to pulmonology billing including National Correct Coding Initiative edits affecting bronchoscopy procedure combinations, documentation insufficient for complex interventional pulmonology codes including endobronchial valve placement and bronchial thermoplasty, and payment disputes regarding professional component billing when technical components performed different facilities. We implement corrective action plans addressing root causes, pursue appeals with payer-specific clinical documentation supporting medical necessity and proper bundling distinctions, and monitor first-pass resolution rates measuring revenue cycle efficiency.

Revenue Cycle Solutions Beyond Claims Submission

Value-Based Care Quality Measure Documentation

The 2025 Pulmonology MIPS Value Pathway requires quality measure documentation including spirometry performance for COPD diagnosis confirmation, appropriate inhaler therapy prescribing, pulmonary rehabilitation referrals, and tobacco cessation counseling supporting value-based payment participation. Documentation demonstrating quality metric achievement affects Medicare payment adjustments through Merit-Based Incentive Payment System scoring requiring systematic outcome tracking.​

Prior Authorization Management for Interventional Procedures

Endobronchial valve placement, bronchial thermoplasty procedures, navigational bronchoscopy systems, and cryobiopsy interventions increasingly require prior authorization demonstrating clinical appropriateness before payers approve high-cost procedures. Authorization delays postpone scheduled procedures while disrupting patient care, requiring systematic tracking systems monitoring approval status and expedited appeal processes for urgent interventions.​

Component Billing for Split Technical and Professional Services

Pulmonary function testing frequently splits between hospital technical components and physician professional interpretation requiring modifier 26 for professional component billing and TC modifier for technical component claims. Split billing coordination prevents duplicate billing violations while ensuring proper reimbursement for both facility resources and physician interpretation services.

Chronic Disease Management and Remote Patient Monitoring

Chronic obstructive pulmonary disease management requires comprehensive care coordination billing using chronic care management codes 99490-99491, remote patient monitoring 99453-99458 for home spirometry or oxygen saturation tracking, and transitional care management 99495-99496 following hospitalizations. Documentation supporting non-face-to-face care coordination time and remote monitoring data review justifies additional reimbursement beyond routine office visits.​

Partner with Specialized Pulmonology Billing Experts

Pulmonology billing complexity demands dedicated expertise understanding respiratory procedure coding nuances, quality payment program requirements, and evolving payer policies affecting pulmonary services reimbursement.

Our specialized pulmonology billing services deliver:

• Expert pulmonary function testing coding with component modifier application
• Bronchoscopy procedure billing accuracy following multiple endoscopy payment rules
• Sleep study claims processing with proper attended versus home testing distinctions
• Critical care and mechanical ventilation documentation supporting time-based billing
• MIPS Value Pathway quality measure tracking supporting value-based payments
• Prior authorization management for interventional pulmonology procedures
• HIPAA-compliant systems protecting patient health information
• Monthly financial reporting with quality metric performance analysis

Pro Health Care Advisors brings boutique service quality ensuring your billing team understands pulmonology practice workflows, knows your payer mix challenges intimately, and advocates persistently for maximum reimbursement on every respiratory care service.