A Pulmonary Function Test (PFT) is a non-invasive diagnostic procedure that assesses how well the lungs are working. It measures lung capacity, volume, and the rate of airflow, helping physicians diagnose and monitor chronic respiratory conditions such as Chronic Obstructive Pulmonary Disease (COPD), asthma, and pulmonary fibrosis. While the procedure itself is standardized, the final cost to the patient is not. The price can differ widely based on where the test is performed and the complexity of the specific measurements taken.
Understanding the Base Cost of a PFT
The sticker price for a PFT before insurance adjustments typically ranges from $150 for a basic screening to over $1,200 for a comprehensive panel. This wide range reflects differences in facility charges and the specific tests included. For cash-paying patients, a standard PFT at a local physician’s office generally costs between $150 and $350. Hospitals frequently bill significantly higher amounts, with uninsured costs often starting at $500 and exceeding $1,000 for the same procedure.
The specific tests performed are tied to Current Procedural Terminology (CPT) codes used for billing. A simple spirometry test, which measures how much air you can exhale and how quickly, is often billed under CPT code 94010. A more complex PFT includes spirometry performed before and after administering a bronchodilator to check for reversibility, coded as 94060. Advanced procedures, such as lung volume measurements (plethysmography) or diffusion capacity, require specialized equipment and time. These advanced procedures substantially increase the base charge of the PFT panel.
Key Variables That Determine the Final Price
Facility Type and Fees
The type of facility is a significant determinant of the final cost. Hospital outpatient departments are typically the most expensive setting due to high operational overhead. They also include facility fees, which are charges for the use of the hospital’s space and resources, added regardless of the test’s complexity. Independent diagnostic laboratories and physician offices generally offer the same quality of testing at a lower price point. These smaller facilities have reduced administrative and operational costs, which translates into lower list prices for procedures like PFTs. Patients can often see a price difference of two to five times higher for the same test when comparing a hospital setting to an independent lab.
Geographic Location
Geographic location also plays a role in price variability, reflecting regional differences in labor costs and market competition. Major metropolitan areas often have higher PFT costs compared to rural or suburban regions. Furthermore, the reimbursement rates negotiated by Medicare and private insurers vary by region. This variation influences the starting price charged by providers in those areas.
Scope of Testing
The scope of testing ordered dictates the overall price. A basic PFT may only involve spirometry to assess airflow obstruction, which is the least costly combination. A comprehensive PFT is a suite of tests that typically includes lung volume measurement to look for restrictive lung disease and diffusion capacity (DLCO) to assess oxygen transfer efficiency. Combining these advanced measurements requires more sophisticated equipment, longer technician time, and more complex interpretation, substantially increasing the total billable charge.
Insurance Coverage and Billing Complexity
Medical Necessity and Authorization
For a PFT to be covered, insurance requires it to be medically necessary. The physician must document a clear medical reason for the test, such as unexplained shortness of breath or monitoring a diagnosed lung condition. The claim submitted must include the correct diagnosis codes (ICD-10-CM) that support the PFT procedures billed under CPT codes. Insurers may deny claims if they determine the test was not medically appropriate or if the documentation is insufficient.
Many insurance plans require prior authorization for comprehensive PFTs, which is an approval from the insurer before the test is performed. If the provider fails to obtain this authorization, the insurer may refuse to pay the claim, leaving the patient responsible for the entire cost. Patients should always confirm this requirement with their insurance company and the testing facility well in advance of the appointment.
Patient Financial Responsibility
A patient’s financial responsibility is determined by their specific plan structure, which includes deductibles, copayments, and coinsurance. The deductible is the amount the patient must pay out-of-pocket annually before the insurance coverage begins to pay for services. Until this deductible is met, the patient will be responsible for the full, contracted rate for the PFT.
Once the deductible is satisfied, the patient may owe a copayment, which is a fixed dollar amount, or coinsurance, which is a percentage of the allowed charge. For example, a plan might require a $50 copay or a 20% coinsurance on the contracted rate for the test. Patients should receive an Explanation of Benefits (EOB) from their insurer, which outlines the total billed amount, the contracted rate the insurer allows, and the portion the patient owes. Reviewing the EOB against the actual bill ensures the patient is only charged the discounted, contracted rate.
Strategies for Managing PFT Costs
Patients can actively manage their out-of-pocket expenses by taking a proactive approach to the billing process.
- Inquire about self-pay or cash discounts before scheduling the procedure. Many providers, especially independent diagnostic labs, offer substantial discounts (20% to 50%) for patients who agree to pay the entire bill upfront.
- Price shop between local facilities. Patients should call multiple providers, comparing the cost of the specific CPT codes ordered by their physician, such as CPT 94060. Comparing quotes from a large hospital versus a standalone pulmonary clinic can reveal significant savings.
- Seek financial assistance programs. Most hospitals have formal financial aid programs, often called “charity care,” that offer discounts or complete write-offs for patients who meet income criteria.
- Ask about interest-free payment plans. Many facilities are willing to establish plans to spread the cost of the procedure over several months.