Battery-operated spirometers permit regular daily measurement of pulmonary function in the home, typically forced expiratory volume in 1 second (FEV-1) and forced vital capacity (FVC). The device has been primarily investigated among lung transplant recipients as a technique to provide early diagnosis of infection and rejection. Home spirometry may also be referred to as ambulatory spirometry.

Home monitoring of pulmonary function is considered investigational.

In 1999, a series of 3 new CPT codes were introduced that specifically describe patient-initiated spirometric recording (i.e., home spirometry) as follows:

94014: Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration, and physician's review and interpretation.

94015: as above parent code, but represents recording only

94016: as above parent code, but represents physician review and interpretation only

The codes are structured similarly to those describing ambulatory event monitoring (see policy No. 2.02.08 ). CPT code 94014 represents the bundled service, while CPT codes 94015 and 94016 separately represent the recording and physician review and interpretation, respectively. CPT codes 94015 and 94016 would be used, for example, if a monitoring service provided the recording, while a separate physician was responsible for the review and interpretation of the recorded data.

In 2009, a new HCPCS code was introduced for spirometers; A9284.

BlueCard/National Account Issues

Global case rates for lung transplantation that provide for a period of outpatient care may include the use of home spirometry.

Immediately postoperatively, lung transplant recipients must be carefully monitored for the development of either rejection episodes or infectious complications. Techniques include complete pulmonary function testing, serial chest x-rays, bronchioalveolar lavage, and transbronchial biopsy. Transbronchial biopsy is thought to be the only objective method of distinguishing between these 2 common complications. Transbronchial biopsy is typically performed on a routine schedule, with additional biopsies performed if the patient becomes symptomatic. Home spirometry has been investigated as a technique to provide daily monitoring to promptly identify presymptomatic patients who may benefit from a diagnostic transbronchial biopsy. However, published data are minimal. Otulana and colleagues reported on the use of home spirometry in an initial case series of 15 heart-lung transplant recipients. (1) The authors hypothesized that the results of routine spirometry might better guide the use of transbronchial biopsy. The authors reported that episodes of rejection or infection were associated with a 10% decrease in FEV-1 and recommended that this decrease should prompt a transbronchial biopsy. However, all patients also had symptoms at the same time, so it is unclear how the spirometry contributed to the decision to perform a transbronchial biopsy. On 9 occasions, the FEV-1 was unchanged at the time of a routine scheduled transbronchial biopsy. Histologic results were normal in these patients.

Fracchia and colleagues reported on a case series of 9 heart-lung transplant recipients who underwent monitoring of lung rejection with home spirometry. (2) Similar to the study of Otulana, patients underwent a “symptom” transbronchial biopsy if their FEV-1 or FVC showed a decrease of 10%. Only 3 patients underwent a symptom biopsy, which revealed moderate rejection. It was not reported whether the patient was clinically symptomatic at that time. In addition, during routinely scheduled transbronchial biopsies, acute rejections were observed even in the face of normal FEV-1 values.

In summary, the paucity of published clinical data does not permit scientific conclusions regarding the clinical use of home monitoring of FEV-1 and FVC. Specifically, there are inadequate data to determine how reductions in FEV-1 and FVC relate to clinical symptoms, and how this information can be used to determine the necessity of transbronchial biopsies.

2003-5 Update

A review of the peer-reviewed literature on MEDLINE from the period of 2002 through October 2005 focused on studies demonstrating a relationship, if any, of earlier detection of infection or lung transplant rejection with home spirometry. No such articles were found. Home spirometry use is also being explored for use by children with asthma or cystic fibrosis to measure changes in lung function longitudinally. However, there were no publications on clinical trials for home spirometry use in children nor evidence that home spirometry provides any greater health advantage over peak flow meters. Therefore, the policy is unchanged.

2006–2007 Update

The literature was reviewed through February 2007. The articles identified did not lead to any changes in the policy statement. A recent publication reported results on using this approach to detect pulmonary complications in recipients of allogeneic stem cell transplants. (3) While the authors concluded it was a useful procedure, further investigation is needed to determine potential impact on outcomes.

2008 Update
A literature search using MEDLINE was conducted for the period March 2007 through May 2008. None of the articles identified lead to a change in the current policy statement. A retrospective cost analysis of home monitoring in 138 lung transplant recipients who were monitored for at least one year found that adherence to a program of home monitoring that included home spirometry was associated with lower overall costs (higher outpatient, lower inpatient). (4) However, there was no comparison group of patients with lung transplant who did not have home monitoring and there are likely patient factors that impact adherence and preclude attributing the cost savings to the program. Regarding home spirometry for asthmatics, a sequence randomized study measuring peak expiratory flow and FEV-1 using both a hospital based pneumotachograph and a home spirometer (Koko Peak Pro) involving 50 asthmatic children aged 6 - 17 years found both clinically and statistically significant differences between measures obtained using the two techniques in a controlled (professionally supervised) clinical setting. (5) The results from each meter were reproducible but not interchangeable. The mean values for both measures were significantly lower when using the home spirometer compared to the hospital spirometer. Neither study provides evidence supportive of an outcomes advantage for home spirometry, therefore the policy statement remains unchanged.

References:

1. Otulana BA, Higenbottam T, Ferrari L et al. The use of home spirometry in detecting acute lung rejection and infection following heart-lung transplantation. Chest 1990; 97(2):353-7.
2. Fracchia C, Callegari G, Volpato G et al. Monitoring of lung rejection with home spirometry. Transplant Proc 1995; 27(3):2000-1.
3. Guihot A, Becquemin MH, Couderc LJ et al. Telemetric monitoring of pulmonary function after allogeneic hematopoietic stem cell transplantation. Transplantation 2007; 83(5):554-60.
4. Adam TJ, Finkelstein SM, Parente ST et al. Cost analysis of home monitoring in lung transplant recipients. Int J Technol Assess Health Care 2007; 23(2):216-22.
5. Brouwer AF, Roorda RJ, Brand PL. Comparison between peak expiratory flow and FEV(1) measurements on a home spirometer and on a pneumotachograph in children with asthma. Pediatr Pulmonol 2007; 42(9):813-8.

Spirometry, Home or Ambulatory