Pulmonology billing requires special attention to beat the industry’s average claim denial rate of 18%. What if the toughest parts of your practice start running smoothly? Most billing services treat a spirometry claim like a standard office visit. We don’t. Nexus io builds a system for your practice to collect faster and more. We combine AI-powered scrubbing with pulmonology-specific expertise to turn your “gray areas” of PFT and sleep study coding into a financially sound system.
Pulmonology reimbursements are volatile. A successful practice has to survive the audit trail that involves capturing the full clinical picture. In pulmonology, the challenge is to establish a clear sequencing of diagnostics.Â
When a patient presents with overlapping COPD and acute respiratory failure, the difference between a paid claim and a denial often comes down to which code is primary. Nexus io connects the complete picture and ensures every claim reflects the full clinical picture before it ever reaches the payer.
Coding for pulmonology services has some of the most complex classifications in medical billing. Multiple procedures can be billed for a single encounter that include spirometry, arterial blood gases, as well as E/M services, and each must contain precise documentation and appropriate modifiers.
We recently reviewed a practice that was losing $3,200 per month on bronchoscopy claims. The issue? Their coders were applying modifier 51 (multiple procedures) when modifier 59 (distinct procedural service) was the correct choice for CPT 31622 (diagnostic bronchoscopy) performed with 31625 (biopsy) on separate lesions. Modifier 51 reduces reimbursement by 50% for the second procedure. Modifier 59 allows full reimbursement when procedures are truly distinct. Our AAPC-certified pulmonology coders understand these distinctions.
The ICD-10-CM codes for respiratory conditions cover codes from category J00-J99, which represent specific codes to denote patients with COPD (J44.x), asthma (J45.x), pulmonary fibrosis (J84.x), and obstructive sleep apnea (G47.33). Use of an unspecified code can result in an audit or a reduction of your payment. Our team reviews every encounter for the highest level of specificity that may be documented.
As a relatively high-cost medical field, pulmonology loses more to billing and coding errors. For instance, one sleep study (polysomnography, CPT 95810) can produce $1,500 to $3,000 in charges. A claim that is denied for a complex bronchoscopy with biopsy (CPT 31625) results in a substantial loss of revenue.
A pulmonary group in Colorado was losing $12,000/month due to the incorrect sequencing of COPD with acute exacerbation (J44.1) codes. Their encounter forms defaulted to unspecified COPD (J44.9), triggering medical necessity denials for hospital follow-up visits. We restructured their encounter templates and implemented pre-visit chart reviews. Result: 22% lift in net collections within 90 days—an additional $8,400 monthly revenue.
Prior authorization requirements for pulmonology services have expanded dramatically. Most commercial payers now require pre-authorization for sleep studies, home sleep apnea testing, pulmonary function tests, and advanced imaging like CT chest scans.
They require both an Epworth Sleepiness Scale score ≥10 AND a documented AHI ≥15 to approve the use of polysomnography (CPT code 95810). If either one of those elements is missing, it will automatically lead to a denial.
Aetna requires a patient to have undergone conservative treatment (weight loss, positional therapy) for 3 months documented in the clinical record before authorization for CPAP (E0601).
We specialize in the aggressive clinical documentation required by UnitedHealthcare and Aetna for Polysomnography (95811), reducing “medical necessity” denials by 40% before the claim is even generated. We maintain direct relationships with major payers and track authorization requirements by procedure code.
Pulmonary patients often need to be provided with coordinated care that usually involves multiple specialties. For instance, a patient with lung cancer needs services from the oncology, radiation oncology, and thoracic surgery. This coordination creates billing complexity—global surgery packages must be properly split when multiple providers are involved, and shared visits require strict incident-to billing compliance. Our billing platform integrates with all major EHR systems, including Epic, Cerner, eClinicalWorks, and Athenahealth.
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Our AAPC-certified coders are pulmonology-specific coding experts. We make sure that CPT codes are assigned correctly for procedures such as basic spirometry (94010), all the way through to complex bronchoscopy with biopsy (31625), thoracentesis (32554), and polysomnography (95810, 95811).
ICD-10-CM diagnosis coding covers the full spectrum of respiratory conditions, including: COPD (J44.0-J44.9), asthma (J45.20-J45.52), pulmonary fibrosis (J84.10-J84.117), obstructive sleep apnea (G47.33), lung cancer (C34.x), and interstitial lung disease.
We ensure proper modifier application – the use of modifier 25, which is for significant, separately identifiable E/M service; the use of modifier 59/XS/XE: XP/XU for distinct procedural service; as well as the correct application of modifier TC/26 to the technical/professional components of diagnostic tests.
We develop claim scrubbing solutions that identify billing inaccuracies before the claims’ submission has taken place, producing an overall first-pass approval rate of 98%. We will file all claims electronically with the respective payor sources within 24 hours of the associated service.
Should a claim be denied, our team will expediently take action to resolve the denial. We identify the root cause of the denial (e.g., coding errors, documentation issues, eligibility issues, or changes in payor policies) and implement an appeal based on the identified root cause.
Our denial management dashboard gives you real-time visibility into all denied claims, appeal status, and recovered revenue. We typically recover 85-90% of appealed denials, compared to the industry average of 55-60%.
Prior authorization requirements for pulmonology services continue to expand. We maintain current authorization requirements for all major payers and proactively obtain approvals for sleep studies, PFTs, advanced imaging, and DME (CPAP/BiPAP).
Payer-Specific Expertise:
Our verification process confirms patient eligibility, benefit coverage, copay/deductible amounts, and prior authorization requirements before each visit. This prevents claim rejections and patient billing surprises.
Our comprehensive RCM solution takes care of every part of your revenue cycle from the moment a patient is scheduled until their payment has been posted. We identify revenue leakage points at every stage and help eliminate them before there is any financial loss.
Key performance indicators we track include days in A/R (target: under 30 days), collection ratio (target: 97%+), denial rate (target: under 5%), and cost to collect. Monthly reporting keeps you informed of your financial performance.
Our RCM service provides insights that can be used to enhance the operations of your revenue cycle by identifying services that are being undercoded, missed opportunities for capturing charges that were not invoiced, and issues with how your agreements with payers are being honored that may be resulting in less revenue than should be expected.
Payers can take anywhere from 90 to 180 days to credential new providers. . Delays mean lost revenue. Our credentialing department oversees and manages the entire credentialing process from the initial application to final approval.Â
We handle CAQH profile maintenance, NPI registration, state license verification, malpractice insurance documentation, and payer-specific credentialing applications. We track application status and follow up aggressively to prevent delays.
For expanding practices, we handle credentialing of groups, facilities, and new service locations (e.g., clinics) to ensure that they are all enrolled with a given payer. We are also responsible for re-credentialing to keep practices actively participating with all payers.
Pulmonology practices are facing increasing scrutiny from Medicare RACs, MACs, and other special investigation units of commercial payers via audits. Our compliance program is designed to assist you in documenting medical necessity, coding appropriately, and maintaining records that are “audit-ready”.Â
We conduct internal audits of coding accuracy, documentation completeness, and modifier usage. Our compliance team stays current with CMS guidelines, LCDs, and payer policy changes that affect pulmonary billing.
If you are subject to an external audit or records request, we offer support in the compilation of documentation, preparation of an appeal letter, and in working with your legal representation regarding optional ways to avoid recoupment of funds.
We are not just another billing company. We are pulmonology revenue cycle experts dedicated to your financial success.
Our coding team holds specialized credentials including CPC, CPMA, and specialty-specific certifications. Lead coder Jennifer Martinez, CPC, CPMA, has 14 years of pulmonology coding experience and trains our entire team on the latest CMS guidelines.
We submit claims within 24 hours of charge entry. Faster submission means faster payment. Our clients average 18 days in A/R compared to the industry average of 35+ days.
Every client gets a dedicated account manager who knows your practice, your providers, and your payer mix. No call centers. No ticket systems. Direct access to your billing expert.
Our clients see an average 25-35% increase in collections within the first six months. We find the revenue you are leaving on the table through undercoding, missed charges, and unworked denials.
Your data security is our priority. We maintain HIPAA compliance and ISO 27001 certification. All staff undergo background checks and regular security training.
Get real-time visibility into your revenue cycle with our client dashboard. Track claims, view denials, monitor A/R, and access detailed financial reports 24/7.
We provide 24/7 support for all pulmonology billing and revenue cycle services, including COPD follow-ups and sleep studies, to bronchoscopy and pulmonary rehabilitation. We ensure accurate CPT and ICD-10 coding, manage prior authorization, and stay current with HIPAA, NCCI edits, and MIPS reporting requirements.Â
Clean claims. Faster reimbursements. No billing discrepancies are pulling your clinical staff away from patient care.
If your denial rate exceeds 8% or your A/R over 90 days is above 15% of total receivables, those numbers are worth a close review with a billing team that works in this specialty. A written findings report comes back in five business days — specific to your payer mix, not a general summary.
Search our knowledge base for answers to complex pulmonology coding and billing questions. These are real questions from real practices.
Can I bill 94060 and 94726 on the same day?
Yes. They are not bundled under NCCI edits. Document medical necessity and a separate interpretation for each. Note that some commercial payers do bundle them — we verify payer policy before submission.
When should I use Modifier 59 vs XE/XP/XS/XU on bronchoscopy claims?
Use the most specific X modifier when possible. XS applies when biopsies are taken from different lobes on the same bronchoscopy (e.g., 31628 RUL + 31628-XS LLL). Without XS, the second code pays $0. Use Modifier 59 only when no X modifier fits.
How do I bill for CPAP/BiPAP compliance monitoring?
Bill CPT 94660 once every 30 days during the compliance period. Document AHI, leak data, usage hours, and a clinical decision — not just a review. If the visit covers additional issues, add the appropriate E/M with Modifier 25. Do not bill 94660 on the same day as a sleep study.
How should I bill for pulmonary rehabilitation services?
Bill G0424 per session, up to 2 sessions per day, 36 sessions maximum. Requires physician supervision, exercise training, education, and a qualifying diagnosis (J44.x for COPD). Prior authorization is required by most payers. Do not exceed 36 sessions without documented medical necessity for extension.
How do I bill a split-night polysomnography with CPAP titration?
Under Medicare, bill 95811 only — not 95810 + 95811. Documentation must show a minimum of 2 hours of diagnostic recording, AHI ≥15, and 3 hours of titration. Commercial payers vary: some allow both codes with Modifier 59. We verify payer policy before submission and appeal incorrect downcodes from 95811 to 95810.
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