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Pulmonology Billing Services Billing & RCM Services
We handle pulmonology medical billing for independent practices: coding, claim submission, payment posting and AR follow-up. Our coders hold CPC and CCS certifications and work at 98.9% coding accuracy across our coding work. We bill all payers and work in the EHR and sleep lab systems you already use.
How Pulmonology Billing Works, and What It Demands From Your Billing Team
Pulmonology billing covers office E/M visits, pulmonary function tests, in-lab and home sleep studies, bronchoscopy and EBUS, pleural procedures, critical care and ventilator management, each with its own bundling and component rules. Coders have to apply NCCI edits to PFT combinations, split professional and technical components when the practice does not own the equipment, and document critical care minutes to Medicare's thresholds. Qualigenix handles that work for pulmonology practices from eligibility to appeals. Call 786-259-0231 to talk through your current numbers.
01
PFT Bundling and NCCI Edits
PFT codes overlap. Spirometry (94010) is part of the pre- and post-bronchodilator study (94060), so billing both on the same date is a bundling error. Lung volumes (94726, 94727) and diffusing capacity (94729, an add-on) each have their own pairing rules under NCCI. A PFT lab that bills every test it ran, code by code, gets denied line by line.
02
Prior Auth for Sleep Studies, Biologics, and Bronchoscopy
Most commercial plans authorize in-lab polysomnography in advance and many require a home sleep test first. Biologics for severe asthma and many bronchoscopic procedures also need authorization, and a missing number turns into a full denial after the service is done.
03
26/TC Splits on PFTs and Sleep Studies
When the practice owns the equipment and does the reading, it bills the global code. When a hospital owns the lab, the pulmonologist bills only the professional component with modifier 26. When the practice runs the test but another physician reads it, it bills the technical component with TC. The wrong split is paid wrong or denied.
04
Critical Care and Hospital Time
Critical care is billed by time. CPT 99291 covers the first 30 to 74 minutes, and 99292 covers each additional 30 minutes, but Medicare counts differently: it pays 99292 only once total time reaches 104 minutes. Ventilator management codes 94002 through 94004 cannot be billed with an E/M on the same date. Notes without start and stop times, or without the total, cannot support either code.
05
Coverage for Home Sleep Tests, Oxygen, and Rehab
Home sleep study billing uses its own HCPCS codes on Medicare claims (G0398 to G0400), and coverage for home sleep testing, home oxygen and pulmonary rehabilitation varies by plan, and Medicare Advantage plans often add their own rules. Patient responsibility should be known before the test, not after the bill.
06
CPAP, Oxygen, and Rehab Medical Necessity
Medicare's national coverage determinations set the documentation bar. For CPAP, the patient must use the device at least 4 hours a night on 70% of nights during a consecutive 30-day period within the first 3 months, and a face-to-face re-evaluation must document the benefit. The DME supplier bills the device, but that claim stands on your notes.
07
26/TC, Frequency, and E/M Denials
Pulmonology denials often come from the wrong component modifier, repeat PFTs or sleep studies inside a payer's frequency window, and E/M visits billed on the same date as a procedure without modifier 25.
08
NCDs, Incident-To, and HIPAA
Pulmonology billing has to follow Medicare's national coverage determinations for CPAP, home oxygen and pulmonary rehabilitation, the incident-to supervision rules when NPs and PAs see clinic patients, and HIPAA for every chart that moves between the practice, the lab and the hospital.
PRECISION: WHAT QUALIGENIX DOES
Qualigenix's Response to Every Pulmonology Revenue Gap
Each fix below matches a gap above, in the same order.
PFT and Procedure Coding
Our coders build each PFT claim from the tests actually reported, apply NCCI pairing rules before submission, and code bronchoscopy and EBUS to the specific approach and sampling documented.
Sleep and Procedure Authorizations
We check each payer's sleep testing and procedure rules, submit authorization requests, and track them until the number is on file.
26/TC Split Billing
We set up each testing location by ownership, so every PFT and sleep study goes out as global, professional or technical, matched to who owns the equipment and who reads the study.
Critical Care Time Capture
We read critical care notes for total time and code 99291 and 99292 to the payer's threshold, applying Medicare's 104-minute rule for 99292 on Medicare claims.
Testing, Oxygen, and Rehab Verification
Before the test or the referral, we confirm coverage, frequency limits and patient responsibility for sleep testing, oxygen and pulmonary rehab.
Coverage-Criteria Review
We review CPAP adherence data, oxygen qualifying results and rehab eligibility against the national coverage criteria and flag missing elements before the claim or supplier order goes out.
Denials and Appeals
We work each pulmonology denial to its root cause and appeal the ones that should be paid. Across our denial management work, 79% of denials are overturned, with an average appeal turnaround under 9 days.
Coverage and E/M Monitoring
We track E/M level distribution, modifier 25 use and testing frequency by provider, and flag patterns that would draw a payer review.
CASE STUDY 01
How a 3-provider podiatry group cleared $214K in aged A/R
THE SITUATION
A 3-provider podiatry group with roughly 60% Medicare payer mix carried $412,000 in A/R, 38% of it past 120 days. Routine foot care claims (11720, 11721, 11055–11057) had stalled on inconsistent Q7/Q8/Q9 modifiers and class-finding documentation, so payers held or partially paid and nobody worked the remainder. Medicare crossover to secondaries was not being posted, and small patient balances were written off.
WHAT QUALIGENIX DID
We ran a full A/R aging segmentation, worked claims by payer and denial reason rather than by date, rebilled the stalled routine-care claims with corrected modifiers, and reactivated secondary and crossover billing.
Key Outcomes & Turnaround
38% to 14%A/R past 120 days
$214,000recovered from aged A/R
90 daysto turn it around
~60%Medicare payer mix
Audited Practice Results
How a solo podiatrist lifted first-pass acceptance to 96%
THE SITUATION
A solo podiatrist coding 320 encounters a month was stuck at 82% first-pass acceptance. Routine foot care went out without the systemic-condition diagnosis pairing and class findings Medicare requires, so it read as non-covered. Wound debridement was coded to the wrong depth (11042 for skin and subcutaneous where the note supported 11043 for muscle and fascia). Same-day E/M with a procedure went out without modifier 25 and got bundled.
WHAT QUALIGENIX DID
We rebuilt the coding workflow: diagnosis-to-CPT pairing rules for at-risk foot care, correct Q-modifier logic, depth-based debridement coding tied to the operative note, and disciplined use of modifiers 25 and 59/XS.
Key Outcomes & Turnaround
82% to 96%first-pass acceptance
+11%per-encounter reimbursement
60 daysto turn it around
320/moencounters coded
Audited Practice Results
How a 2-location podiatry practice cut its denial rate by two-thirds
THE SITUATION
A 2-location podiatry practice sat at a 19% denial rate, mostly Medicare routine-foot-care and nail-debridement rejections. The denials clustered in three buckets: medical-necessity rejections on routine foot care (missing qualifying diagnosis and class findings), frequency-edit denials on nail debridement billed inside the 60-day window, and missing Q modifiers that flagged services as non-covered.
WHAT QUALIGENIX DID
We built a front-end denial-prevention layer, checking eligibility and coverage against payer LCDs before claims went out, plus a structured appeal workflow with documentation templates mapped to each denial reason.
Key Outcomes & Turnaround
19% to 6%denial rate
$68,000recovered on appealed claims
4 monthsto turn it around
2 locationspractice size
Audited Practice Results
Pulmonology Coding Across the Clinic, Lab, Sleep Center, and ICU
Our coders work every service line a pulmonology practice bills.
PFTs (94010, 94060, 94726, 94727, 94729, 94618)
Spirometry, bronchodilator studies, lung volumes, diffusing capacity and pulmonary stress testing, combined under NCCI rules.
COMPLIANCE
How We Keep Pulmonology Billing Compliant
Qualigenix keeps pulmonology billing compliant by applying NCCI edits to every PFT combination, billing critical care only to the time the note documents, and checking CPAP, oxygen and rehab documentation against Medicare's national coverage criteria. Underbilling leaves earned revenue unpaid. Overbilling creates audit exposure and repayment demands. We hold a 98.6% compliance and audit pass rate and an over/undercoding rate under 2%. All work is HIPAA compliant, and patient data is handled under strict security controls.
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Audit Pass Rate
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Variance Threshold
Why Pulmonology Practices Choose Qualigenix
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IMPROPER PAYMENT RATE
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FROM DOC GAPS
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FROM CODING ERRORS
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PAID IN ERROR
QUESTIONS BUYERS ASK
Frequently Asked Questions
Qualigenix charges a percentage of collections, so our fee rises and falls with what your practice is paid. We bill all payers. Call 786-259-0231 for a quote based on your claim volume and payer mix.
We bill each in-lab study (95810, 95811) and home sleep study (95806, G0398–G0400) as global, professional (modifier 26) or technical (modifier TC) based on who owns the equipment and who interprets it, and we check each payer's authorization and home-test-first rules before the study.
We check adherence data, qualifying test results and face-to-face re-evaluation notes against Medicare's national coverage criteria before the order or claim goes out, and flag what is missing.
Yes. We take over open and aged pulmonology AR, sort it by payer and age, and work it alongside new claims. Across our AR work, days in AR have dropped from 54 to 36.
We build each PFT claim from the tests in the report and apply NCCI pairing rules before submission, so codes such as 94010 are not billed on the same date as 94060.
We code critical care from the total time in the note and apply each payer's threshold, including Medicare's rule that 99292 is billed only once total time reaches 104 minutes.
Yes. Qualigenix is system-agnostic and has worked across 133 EMR/EHR platforms, so we work inside your current systems.
Our average onboarding takes 6 days, covering system access, testing-location setup by ownership, payer enrollment checks and a review of your open AR.