1. Office Spirometry Maria V. Gibson, MD, PhD

2. Office spirometry indications Risk stratification, Evaluating disability , Occupational exposure >45 years old current or former smokers, Symptoms: prolongedcough, dyspnea, wheezing Assessing severity or progression of Asthma ,COPD, Sarcoidosis, pulmonary fibrosis, multiple sclerosis Am J Respir Crit Care Med , 2001, Jama 1997

3. Contraindications for spirometry • Acute disorders affecting test performance (e.g., vomiting, nausea, vertigo) • Hemoptysis of unknown origin • Pneumothorax • Recent abdominal or thoracic surgery • Recent eye surgery • Recent myocardial infarction or unstable angina • Thoracic aneurysms

4. Other benefits of procedure • Easy to perform, noninvasive • Performed by the trained staff • Time to read the test < 3 min • Increasing number of patients needed this test

5. Coding • 94010 : 1.04 RVU • Spirometry, graphic record, total and timed vital capacity, expiratory flow rate measurement, with or without maximal voluntary ventilation • 94060: 1.79 RVU • Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration

6. Coding • 47 yo male smoker came in to f/u persistent cough. You performed spirometry with bronchodilator • E/M code 99214 • Modifier 25, 94060 • ICD code: • Chronic bronchitis • PFTs with bronchodilator • Documentation: • Note for the visit: template ( chronic bronchitis) • In the Plan: procedure note with VEV1, FVC and FEV1/FVC documentation • Copy of the report scanned in special note studies

7. Reimbursement • Reimbursement ( 94010, 94060) • Medicare $35.21 /$70 • Medicaid $37.49/$74 • BC/BS $74.00/ $148

8. Earning potential for office spirometry at DFM+ UFM $6,256 118 445 $14,880

9. Equipment IQmark digital Spirometer Recommended for adults only Provides Pre and post- bronchodilator testing

10. Spirometry techinques • Step1: Equipment calibration • Step 2: enter correct weight, height , gender • Step 3: Coaching patient • Step 4: Check for adequacy

11. Terminology • FEV1 • Volume of gas exhaled in 1 sec during performance of FVC • Forced Vital Capacity (FVC) • the total volume of air that can be exhaled during a maximal forced expiration effort • FEF25-75% • maximal midexpiratory flow • FEV1/FVC %ratio— • The percentage of the FVC expired in one second. (FEV1 /FVC × 100)

12. a healthy person (B) severe obstruction (emphysema), • (C) severe restriction from interstitial disease (radiation fibrosis), (D) upper airways obstruction (tracheal stenosis), • E) poor effort.

13. Spirometry interpretation

14. How to check validity?

15. How to determine ventilatory pattern?

16. How to determine severity ?

17. Bronchodilator challenge test response • FVC increase 200mL or • FEV1 increase 12% or • FEF 25-75% increase15- 25% • “ Improved after bronchodilation” • “Reversible airway disease”

19. Documentation • 1.Progress note • Indication • Patient effort • Assessment • 2. Scanned original report in Special Studies