PFT and bronchoscopy coding, sleep and biologic prior authorization, CPAP and oxygen documentation, patient marketing and a claims portal for pulmonary practices, built on CMS rules and your payers' own policies.
Quick answer
Pulmonology billing services manage the claims a lung and sleep practice creates: pulmonary function tests and their NCCI bundling, bronchoscopy, sleep studies, pulmonary rehab and chronic care management, plus biologic prior authorization and the notes CPAP and oxygen suppliers need. RCM Finder pairs that billing with front-desk assistants, patient marketing and a claims portal.
Pulmonology billing is different because one practice runs several billing systems: visits, a lung function lab, bronchoscopy, sleep testing, rehab and care management. CPAP and home oxygen are billed by a supplier, yet those claims rest on your notes.
Each service follows its own rulebook, from NCCI edits and global surgery rules to DME MAC policies and each plan's biologic criteria.
Under CMS's CY 2026 Physician Fee Schedule fact sheet, the conversion factor is $33.40 for clinicians who are not qualifying APM participants, up from $32.35. A -2.5% efficiency adjustment applies to services that are not time-based; E/M and care management are exempt. Virtual direct supervision is now permanent for pulmonary rehab and diagnostic tests.
CMS's 2027 proposed rule fact sheet (July 14, 2026) proposes a $32.84 conversion factor for clinicians who are not qualifying APM participants. It also proposes that when the same physician or practice bills an office or outpatient E/M visit on the same day as a 0-, 10- or 90-day global procedure, only the most expensive service is paid in full and the rest at 50%. That would include visits on bronchoscopy days. Both are proposals, not final policy; check the final rule.
A pulmonology practice needs referrals coming in, drugs and tests approved before the visit, claims coded to the edits, and software that shows every claim. Each pillar handles one.
Revenue leaks at the handoffs: a lapsed biologic approval, a CPAP follow-up on day 95, a nebulizer treatment billed on top of a bronchodilator study.
Our healthcare digital marketing builds demand from local patients searching for lung and sleep care and from the primary care offices that refer to you, through local SEO, Google Ads and reputation work.
Our virtual medical assistants for pulmonology work your front desk on your time zone. They verify eligibility, start biologic and sleep-study authorizations and book the follow-ups that CPAP and oxygen coverage depend on.
Our end-to-end pulmonology revenue cycle management covers coding support, claim scrubbing, denial management and A/R follow-up, with added checks for NCCI lab pairs, bronchoscopy bundling, modifier 25 and rehab KX.
Our practice management system tracks every claim by stage, applies specialty-aware billing logic per claim, checks data completeness before submission and flags payments below the expected amount.
HHS tracking guidance says tracking on appointment pages can collect patient data and that a cookie banner is not a HIPAA authorization; a 2024 court order vacated part of it. We keep tracking off scheduling forms without a vendor BAA.
Find where your pulmonology claims leak
We review recent claims and your authorization log, then show what to fix first. Pricing is quoted after the audit.
The CMS documents we reviewed point to a few denial triggers: bundled tests, same-day visits on 0-day procedures, sleep tests outside coverage, and session or monthly limits. Codes are in our own words (the AMA owns CPT descriptors); check current code sets before billing.
| Service family | Code examples (our wording) | Billing nuance | Typical denial trigger |
|---|---|---|---|
| Spirometry and PFT lab | 94010 (spirometry); 94060 (before and after bronchodilator); 94726 (lung volumes); 94729 (gas transfer, add-on) | The bronchodilator dose is part of 94060; the drug is billable. Repeat efforts are one unit. | 94640 billed for the 94060 dose; extra units |
| Inhalation treatment and teaching | 94640 (nebulized treatment for acute obstruction); 94664 (inhaler teaching) | 94640 once per episode; a second episode the same day takes modifier 76 | Spirometry billed around an acute 94640; 94664 with 94640, same device |
| Exercise testing | 94618 (pulmonary stress test, such as a 6-minute walk); 94621 (cardiopulmonary exercise test) | 94621 includes its spirometry, oximetry and ECG monitoring | 94618 billed with 94621 in one encounter |
| Bronchoscopy and EBUS | 31622 (diagnostic); 31624 (lavage); 31628 (lung biopsy, one lobe); 31652, 31653 (EBUS, 1–2 or 3+ node stations); 31627 (navigation add-on) | 0-day global; fluoroscopy is integral; a same-day visit needs a significant, separate reason (modifier 25) | 31622 with a surgical bronchoscopy; fluoroscopy billed separately |
| Sleep testing | 95810 (in-lab study); 95811 (in-lab study with PAP titration); 95806, G0399 (home tests) | Ordered by the treating practitioner; WPS requires credentialed readers and a sleep evaluation before home tests | Home test despite moderate to severe lung disease, neuromuscular disease or heart failure (WPS); chronic insomnia |
| Pulmonary rehab | 94625 (without continuous oximetry); 94626 (with it); both replaced G0424 from January 1, 2022 | COPD GOLD II–IV, or COVID-19 with symptoms 4+ weeks; plan signed every 30 days | Sessions past 36 without MAC approval or the KX your MAC asks for; unsigned plan |
| Chronic care management | 99490 (20 staff minutes); 99439 (each added 20); 99491 (30 practitioner minutes); 99424–99427 (principal care) | 2+ chronic conditions lasting 12+ months; consent; one practitioner per month | Another practice billed CCM that month; no consent on file |
Sources: CMS NCCI Policy Manual 2026, chapters V and XI; CMS MLN907166 (2025); WPS LCD L36839 (2025); AASM sleep codes; 42 CFR 410.47; CMS CR 12613 (2022); First Coast (2026); CMS MLN909188 (2025); AAPC code summaries. Rules vary by contractor and payer.
CMS's 2026 NCCI manual says 94060 already includes giving the bronchodilator, so billing 94640 for that dose is a misuse; the drug itself can be billed. When 94640 treats acute obstruction, spirometry around it is not billed separately. A limited exam tied to the test is not a separate E/M; a significant, separate visit takes modifier 25. For hospital reads, Noridian, a Medicare contractor, allows modifier 26 only on codes with a professional and technical split.
Under the 2026 NCCI chapter on respiratory surgery, a diagnostic bronchoscopy (31622) is not billed with a surgical one, and fluoroscopy is part of the procedure. For 0-day procedures, the global surgery booklet includes a procedure-day visit unless it is significant and separately identifiable. Confirm each code's global days in the fee schedule look-up.
Coverage turns on documented severity: GOLD stage for COPD, AHI for sleep apnea, eosinophil counts for biologics. See our guides to COPD ICD-10 coding and obstructive sleep apnea ICD-10 code G47.33.
For CPAP and home oxygen, the supplier bills Medicare, but the claim rests on your chart: the visit before the sleep test, the follow-up between day 31 and day 91, and an oxygen test done at the time of need.
NCD 240.4.1 covers in-lab polysomnography and listed home test types ordered by the treating practitioner. WPS, the MAC for Indiana and Michigan among other states, adds rules in LCD L36839: home tests only after a comprehensive sleep evaluation, none for moderate to severe lung disease, neuromuscular disease or heart failure, and credentialed readers. Other MACs may differ. For sleep in neurology, see our neurology billing services guide.
The DME MAC PAP device LCD L33718 requires an in-person visit before the sleep test and an AHI or RDI of at least 15, or 5 to 14 with documented symptoms or conditions such as hypertension. Coverage starts as a 12-week trial under NCD 240.4. To continue, the practitioner re-evaluates the patient in person between day 31 and day 91 and documents benefit and use of 4 or more hours a night on 70% of nights in 30 consecutive days. Per policy article A52467, the supplier adds KX only when criteria are met; see our guide to DME billing modifiers.
NCD 240.2 and the DME MAC oxygen LCD L33797 set Group I at an arterial PO2 at or below 55 mm Hg or saturation at or below 88% at rest, with sleep and exercise variants. Group II is 56 to 59 mm Hg or 89%, plus edema suggesting heart failure, pulmonary hypertension or a hematocrit over 56%. Test at the time of need (for inpatients, within 2 days of discharge), and never by the supplier. Under policy article A52514, Group II needs a retest on days 61 to 90 and a new order; suppliers report the group with N1, N2 or N3.
Start prior authorization at scheduling. In pulmonology the heavy items are biologics for severe asthma and COPD, sleep studies and PAP, and each plan writes its own criteria.
UnitedHealthcare's commercial IL-5 inhibitor policy (effective October 1, 2026) is a typical example. For severe asthma it asks for poor control despite maximal inhaled therapy, blood eosinophils of at least 150 cells/μL and a pulmonologist or allergist prescriber. Approvals last up to 12 months; renewal needs a documented response.
Since January 1, 2026, the CMS-0057-F rule has required Medicare Advantage, Medicaid and CHIP plans to decide expedited requests in 72 hours and standard ones in seven calendar days. Drug prior authorizations are excluded, so biologics run on each plan's own clock.
For sleep, the AASM prior authorization toolkit checklist tells practices to document a failed or inadequate home sleep test, or a contraindication, when they request an in-lab study. In the AMA’s 2025 survey of 1,000 physicians (released May 2026), physicians averaged 40 prior authorizations and 13 hours of physician and staff time a week.
| Rule | Source | What the VMA checks |
|---|---|---|
| IL-5 biologics, severe asthma: eosinophils 150 cells/μL or more, maximal inhaled therapy, specialist prescriber; up to 12 months | UHC policy 2026D0055AA (Oct 1, 2026) | Eosinophil result, exacerbations, current inhalers; renewal date logged |
| Self-administered Fasenra and Nucala usually go to the pharmacy benefit | UHC policy 2026D0055AA | Medical or pharmacy benefit confirmed before the first dose |
| 72-hour and 7-day decisions for MA, Medicaid and CHIP; drugs excluded | CMS-0057-F (from Jan 1, 2026) | Due date logged for test requests |
| In-lab study request: document a failed or inadequate home test, or a contraindication | AASM toolkit checklist | Prior home test or contraindication on file |
| Medicare home test: sleep evaluation first; not with moderate to severe lung disease, neuromuscular disease or heart failure | WPS LCD L36839 (2025) | Evaluation note dated before the test |
| PAP: in-person visit before the test; re-evaluation on days 31–91 | DME MAC LCD L33718 (2024) | Follow-up booked at setup |
| Oxygen: test at the time of need, not by the supplier; Group II retest on days 61–90 | NCD 240.2; LCD L33797; A52514 | Test date, performer and group recorded |
Sources: UnitedHealthcare policy 2026D0055AA (2026); CMS-0057-F fact sheet (2024); AASM Prior Authorization Toolkit (undated); Medicare Coverage Database WPS L36839 (2025), L33718 (2024), L33797 and A52514 (2023), NCD 240.2 (2021). Always check the member's current plan.
For the full workflow, read our prior authorization guide for providers.
See what lapsed approvals and denials cost you
Enter your claim volume and denial rate to estimate what your pulmonology practice is losing.
Pulmonary rehab and chronic care management both run on a calendar: session counts, a plan signed every 30 days and care minutes counted per month.
Under 42 CFR 410.47, Medicare covers pulmonary rehab for COPD in GOLD stages II to IV on the treating physician's referral, and for COVID-19 with respiratory symptoms lasting at least four weeks. A physician signs the plan every 30 days. Medicare allows two 1-hour sessions a day and 36 sessions, plus 36 more with MAC approval. A 2022 CMS transmittal (CR 12613) retired the older G0424 code after December 31, 2021 and added 94625 and 94626 from January 1, 2022. First Coast, a Medicare contractor, asks for the KX modifier on medically necessary sessions 37 to 72. Other MACs may set this differently, so check yours.
CMS's chronic care management booklet (MLN909188, June 2025) requires two or more chronic conditions expected to last at least 12 months, consent, and an initiating visit for new patients or those not seen within a year. 99490 covers 20 minutes of clinical staff time a month; 99491 covers 30 minutes of the practitioner's own time. Only one practitioner can bill CCM a month, and some specialists may bill it.
Ask whether primary care already bills CCM. See our chronic care management coding guide, our telehealth billing guide and, for cardiac rehab, our cardiology billing services page.
Stay in-house if your coders know the lab and bronchoscopy edits and your front desk has time for approvals. Use a billing-only vendor if claims are the only gap. Choose a combined partner when problems span both.
| Job | In-house team | Billing-only vendor | Four-pillar partner (RCM Finder) |
|---|---|---|---|
| Biologic and sleep-study approvals | Front desk, between calls | Usually left to the practice | VMA starts each request and tracks renewals |
| PFT and bronchoscopy bundling | Depends on one coder | Fixed after the denial | Checked against NCCI before submission |
| CPAP and oxygen notes for suppliers | Handled when records are requested | Usually out of scope | Follow-ups and retests booked at setup |
| Rehab sessions and CCM months | Spreadsheets or EHR reminders | Billed when the practice sends data | VMA keeps the calendar; RCM bills on eligible dates |
| Referral growth and reviews | A separate agency, or nobody | Not included | Marketing pillar tied to booked consults |
| Reporting | EHR reports | Claim reports only | Portal and dashboards, referral to paid claim |
| Cost structure | Salaries, benefits, turnover | Varies; ask how fees are set | Quoted after a free practice audit |
We start with a free audit and change nothing until you see the findings. We build our billing pipeline around how claims actually move through a practice: registration, charge entry, submission, payment and follow-up. For pulmonology, we add the checks on this page.
We review recent claims, denial reasons and your authorization log.
We put a Business Associate Agreement in place before accessing patient data. Then we work inside your existing EHR (for example PrognoCIS, eClinicalWorks or athenahealth).
Your MAC, DME MAC, NCCI and biologic policy rules become a pre-visit checklist and portal workflow rules.
VMAs start approvals and book PAP and oxygen follow-ups. Claims are scrubbed, submitted and worked through denials and A/R.
Each week we review denials by reason, A/R days, approvals cleared before the visit and new referrals.
Talk to us about your pulmonology practice
Tell us your lab and sleep mix and your hardest payer. We will tell you honestly whether we fit.
Any billing vendor that handles your patients' data is a HIPAA business associate. Get a Business Associate Agreement before they have any access, and check how they limit and log that access.
HHS guidance names billing and claims processing as business associate work; subcontractors need their own agreement. The minimum necessary standard limits use of patient data to what each task needs. The Security Rule's technical safeguards are access control, audit controls, integrity, person or entity authentication and transmission security.
We use role-based access, audit logging and encrypted (HTTPS) connections, and we put a Business Associate Agreement in place before accessing patient data. For your own side, see our HIPAA compliance checklist for medical practices.
We would rather tell you now than after you sign. Here is where we fit and where we do not.
A good fit if you are
Probably not a fit if you are
What we would do first if we were running your practice's revenue cycle tomorrow.
We build the NCCI pairs into charge capture: no 94640 for the 94060 dose and one unit per test.
The re-evaluation must fall between day 31 and day 91. We book it when therapy starts.
Each note should show the test date, who performed it and the conditions. For Group II, we book the day 61 to 90 retest right away.
Under UnitedHealthcare's IL-5 policy, approvals last up to 12 months. We log each renewal date and gather response data early.
Only one practitioner can bill CCM in a month, so we check before your staff log a minute.
Rehab coverage depends on GOLD stage II to IV. We confirm the stage and referral are charted and flag sessions 37 and up for your MAC's approval and KX rules.
They cover coding support, claim scrubbing, submission, denial management and A/R follow-up for pulmonary visits, lung function tests, bronchoscopy, sleep studies, pulmonary rehab and chronic care management. A good service also handles biologic and sleep-study prior authorization and checks that your notes support the CPAP and oxygen claims suppliers file. We add front-desk assistants, patient marketing and a claims portal, so one team owns the process from referral to payment.
Sometimes, but not for the same dose. CMS's 2026 NCCI manual says a before-and-after bronchodilator study (94060) includes giving the bronchodilator, so billing 94640 for it is a misuse; the drug can be billed. When 94640 treats acute airway obstruction, spirometry around it is not billed separately. 94640 is reported once per episode of care; a second episode the same day takes modifier 76.
Under DME MAC LCD L33718, the treating practitioner sees the patient in person before the sleep test, and the test must show an AHI or RDI of 15 or more, or 5 to 14 with documented symptoms or conditions. Coverage starts as a 12-week trial. To continue, the practitioner re-evaluates the patient between day 31 and day 91 and documents benefit and use of 4 or more hours a night on 70% of nights in 30 consecutive days.
The treating practitioner orders and evaluates it, and the practitioner or another qualified provider or laboratory performs it. Under NCD 240.2 and the DME MAC oxygen LCD, a DME supplier is not a qualified provider, so supplier-run tests do not count. The test must be done at the time of need, which for a hospital inpatient means within 2 days of discharge.
Usually yes, under each plan's drug policy. UnitedHealthcare's commercial IL-5 inhibitor policy, for example, asks for severe asthma with poor control, a baseline eosinophil count of at least 150 cells/μL and a pulmonologist or allergist prescriber, with approvals of up to 12 months. The CMS-0057-F deadlines of 72 hours and seven calendar days do not apply, because drug prior authorizations are excluded from that rule.
Yes. CMS says some specialists may bill CCM. The patient needs two or more chronic conditions expected to last at least 12 months, documented consent, and an initiating visit if new or not seen in the past year. Only one practitioner can bill CCM for a patient in a calendar month, so check whether the primary care office already does. For one high-risk condition, principal care management may fit instead.
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Pricing is quoted after the audit, based on your volume and the services you choose. Prefer to talk? Call +1 (302) 556-2288.
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