Pulmonary Function Tests are generally covered by Medicare, provided the service meets specific requirements. These diagnostic procedures are an important tool used by medical professionals to assess respiratory health. Medicare coverage is typically available when the tests are ordered by a physician and are considered necessary for a patient’s care.
Understanding Pulmonary Function Tests
Pulmonary Function Tests (PFTs) are non-invasive procedures that provide objective measurements of how well the lungs are working. These tests assess lung volume, capacity, rates of flow, and the efficiency of gas exchange. Spirometry is the most common PFT, measuring the amount of air a person can inhale and exhale, and how quickly they can forcibly exhale air. Specific measurements include the Forced Vital Capacity (FVC) and the Forced Expiratory Volume in one second (FEV1), which are compared to predicted values.
A complete PFT may also include lung volume measurement, to determine the total air the lungs can hold. A diffusion capacity test (DLCO) evaluates how effectively oxygen moves from the air sacs into the bloodstream. Physicians order PFTs primarily to diagnose conditions like Chronic Obstructive Pulmonary Disease (COPD), asthma, or restrictive lung diseases, or to monitor disease progression and assess treatment effectiveness.
Medicare Part B Coverage Details
PFTs, as outpatient diagnostic services, fall under Medicare Part B, which covers doctor visits, outpatient care, and certain medical equipment. Part B coverage extends to diagnostic tests performed in a doctor’s office, clinic, or hospital outpatient department. For the service to be covered, the provider or facility performing the test must accept Medicare assignment, meaning they agree to accept the Medicare-approved amount as full payment.
The coverage of outpatient diagnostic services is based on federal statutes that establish payment rules for Part B services. These laws define the framework under which Medicare reimburses for tests that are deemed reasonable and necessary for the diagnosis or treatment of illness or injury.
Establishing Medical Necessity for Coverage
Coverage for a Pulmonary Function Test is directly dependent on it being determined “medically necessary” by Medicare standards. This means the test must be ordered by a treating physician to diagnose a specific disease or injury, or to manage a known condition. If the test is considered experimental, performed for research purposes, or is a routine screening without specific symptoms, coverage may be denied.
To establish medical necessity, the physician must document the patient’s symptoms or existing diagnosis that justifies the test. This documentation is converted into specific billing codes (ICD-10 codes) that must align with Medicare’s coverage policies. If the submitted code does not support the need for the PFT, Medicare will not pay. If medical necessity is questionable, the patient should receive an Advance Beneficiary Notice of Noncoverage (ABN) before the test, informing them they may be financially responsible.
Patient Out-of-Pocket Costs
Even when a PFT is covered by Medicare Part B, the beneficiary is responsible for certain out-of-pocket costs. The first financial obligation is meeting the annual Part B deductible. Medicare will not begin paying its share until the beneficiary has paid this deductible amount for their covered Part B services.
Once the deductible is met, the patient is responsible for a 20% coinsurance of the Medicare-approved amount for the PFT. If the PFT is performed in a hospital outpatient setting, the patient may also incur a copayment. Medicare Advantage plans (Part C) must cover the same benefits as Original Medicare, including PFTs, but the specific out-of-pocket costs are determined by the individual plan’s structure.