Medicaid & Marketplace Pulmonary Function Testing Edit Effective April 1, 2023

Date: 02/24/23

Dear AZ Complete Health & Care1st Providers & Staff:

Pulmonary function tests (PFTs), also known as lung function tests, include a variety of tests to check how well the lungs are working. PFTs are indicated for evaluation of respiratory symptoms such as cough, wheezing, dyspnea, and chest pain, response to bronchodilator therapy, effect of workplace exposure to dust or chemicals, and pulmonary disability. They can also be used to assess severity and progression of lung diseases, such as asthma, and chronic obstructive lung disease. PFTs can measure obstructive, restrictive, and diffusion defects and respiratory muscle function as well as aid in preoperative assessment or monitoring of disease progression and prognosis. Normal test values are calculated based on age, height, and gender. It is the policy of health plans affiliated with Centene Corporation® that pulmonary function testing is medically necessary for members/enrollees aged three years and above when certain criteria are met.

Centene, our parent company, is implementing medical necessity payment edits denying PFTs when not meeting diagnosis and age requirements.  This edit will impact AzCH-CCP and Care1st Medicaid claims and Ambetter Marketplace claims.

Impacted CPT codes:

94010, 94060, 94070, 94200, 94375, 94450, 94617, 94618, 94619, 94621, 94680, 94681, 94690, 94726, 94727, 94728 and 94729

ICD-10-CM diagnosis codes that support coverage criteria are detailed in the Centene clinical policy CP.MP.242, which we are adding to our websites. The policy is being placed in the following location:

·         www.azcompletehealth.com: For Providers > Provider Resources > Clinical & Payment Policies > Clinical Policies

·         www.care1staz.com: For Providers > Provider Resources > Practice Guidelines > Clinical Policies

Effective 4/1/2023, if a PFT on the above list is billed without a corresponding supporting diagnosis and/or does not meet the age requirements, it will not be reimbursed. Below are the denial codes and descriptions that will be present on the Explanation of Payment.

·         PFT billed without a supporting diagnosis: EXyE – procedure code is disallowed with this diagnosis code(s) per plan policy

·         PFT billed for a member that doesn’t meet the age requirement: EXyC not medically necessary or ineligible service per Centene Policy

AzCH providers and staff:

If you have questions, please contact your AzCH Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.

Care1st providers and staff:

If you have questions, please call Provider Network Operations at 1-866-560-4042 (Options in order: 5, 7) or email SM_AZ_PNO@care1staz.com.