How to Start a
Pulmonary Practice

Define Your Pulmonary Medicine Scope

Pulmonary medicine can combine ambulatory consultation, testing, hospital care, procedures, and longitudinal disease management. A practice may focus on COPD, asthma, interstitial lung disease, pulmonary hypertension, chronic cough, abnormal imaging, lung nodules, lung cancer screening, or sleep apnea.

Select a scope that reflects the physician team's training, local referral need, hospital access, equipment capacity, and staffing. A consultation-heavy model can open with office visits and selected pulmonary function testing; a more complex model may include ICU coverage, bronchoscopy, and formal screening pathways.

Create referral and escalation criteria early. Severe hypoxemia, suspected pulmonary embolism, hemoptysis, acute exacerbation, rapidly progressive ILD, and concerning imaging findings may require emergency, inpatient, or multidisciplinary intervention.

Board Certification and Clinical Governance

ABIM board certification in pulmonary disease is an important credential for pulmonary specialists and may affect payer enrollment, hospital privileges, and referral confidence. Verify licensure, certifications, competency, and scope for each clinician before launch.

The medical director should approve protocols for triage, diagnostics, biologic treatment, oxygen and device referrals, urgent results, hospital transfers, and quality review. Advanced practice clinicians need clearly defined roles consistent with state and payer rules.

Clinical governance should include regular review of adverse events, delayed follow-up, abnormal PFTs, imaging results, medication access, and communication with referring teams.

Spirometry and PFT Operations

Spirometry is a common entry point for office-based pulmonary diagnostics. Code 94010 is commonly associated with spirometry, but billing must match services provided, documentation, and payer policy. Expanded PFT capability may require additional equipment, protocols, personnel, and interpretation processes.

Quality assurance is central. Staff need training in patient coaching, acceptability, reproducibility, infection control, equipment calibration, and documentation. Physicians should have a defined process for reviewing and communicating interpretations.

Before acquiring equipment, validate expected volume, reimbursement, clinical need, maintenance support, and space. Poor-quality studies create clinical and billing risk even when the machine is technically available.

Bronchoscopy and Hospital Privileges

Bronchoscopy is typically performed in a hospital or ambulatory surgery center rather than a standard outpatient office. The pulmonologist must satisfy facility credentialing, privilege, documentation, staffing, sedation or anesthesia, infection control, and emergency-readiness requirements.

A startup should build hospital relationships early if procedures are part of the strategy. Clarify block time, referral patterns, pathology and imaging coordination, post-procedure follow-up, on-call coverage, and quality participation.

Privileges do not replace a practice's own risk management. Confirm malpractice coverage, informed consent processes, results communication, and escalation procedures across the office and facility settings.

• ✓Start facility credentialing early because it can take months.
• ✓Confirm procedure, sedation, and emergency requirements with the facility.
• ✓Align malpractice coverage with bronchoscopy and hospital activity.
• ✓Create a reliable pathology, imaging, and follow-up communication loop.

LDCT Lung Cancer Screening Programs

A low-dose CT lung cancer screening program is more than an imaging order pathway. It needs an eligibility process, referral or ordering workflow, imaging partnership, results tracking, and follow-up plan for suspicious findings. Shared decision-making and documentation requirements may apply depending on payer and program design.

Coordinate closely with radiology, primary care, oncology, thoracic surgery, and navigation teams. The clinic should be able to close the loop on results, incidental findings, annual screening reminders, and urgent referrals.

Do not market screening as a generic scan. Eligibility and clinical appropriateness must guide invitations and orders.

Asthma Biologics and Prior Authorization

Biologics such as Dupixent and Nucala can be important options for appropriate asthma patients, but access frequently depends on detailed prior authorization. Payers may require diagnosis, severity, prior controller therapies, exacerbation history, biomarker data, and evidence of ongoing response.

Develop an authorization team workflow with indication-specific templates, renewal calendars, appeal ownership, specialty pharmacy coordination, and patient updates. Clinical teams should retain authority over alternatives, bridge planning, safety monitoring, and escalation when access delays occur.

If the practice administers medications on site, add storage, inventory, reaction management, and billing controls.

• ✓Verify benefit design and specialty pharmacy requirements.
• ✓Use payer-specific documentation checklists.
• ✓Track renewals and objective response measures.
• ✓Maintain medication storage and adverse-reaction protocols when applicable.

Billing, Coding, and Critical Care

Pulmonary billing may include evaluation and management services, spirometry, PFTs, imaging coordination, procedures, and critical care services when qualifying ICU care is provided. Code 31622 is commonly associated with bronchoscopy and 71250 is commonly associated with CT chest imaging, but coding depends on the service actually furnished and payer policy.

Critical care billing requires careful attention to time, medical necessity, documentation, and payer requirements. It should not be treated as an automatic consequence of seeing an inpatient.

Build charge capture and audit processes around high-risk service lines. Confirm that test reports, procedure notes, authorization records, and clinical documentation support claims.

Telemedicine for COPD Management

Telemedicine can support selected COPD follow-up, inhaler education, medication reconciliation, smoking cessation support, and monitoring conversations. It must be clinically appropriate and should not delay in-person evaluation for acute respiratory symptoms or unstable patients.

Document patient location, consent, clinical assessment, limitations of the remote encounter, emergency instructions, and follow-up plan. Clinicians generally need licensure where the patient is located.

A telemedicine program can be strengthened by clear triage scripts, pulse oximetry guidance where appropriate, remote monitoring governance, and rapid access to in-person or emergency care.

Startup Budget and Facility Planning

Outpatient pulmonary practices often require approximately $200,000 to $600,000 in startup capital. Variables include leasehold improvements, staffing, credentialing delays, PFT equipment, technology, insurance, working capital, and geographic market conditions.

Build the financial plan around realistic ramp assumptions. New payer enrollment, referral development, prior authorization labor, equipment maintenance, and delayed collections can materially affect cash flow.

Plan space for examination rooms, spirometry or PFT operations, infection control, equipment storage, staff workstations, and patient accessibility. If procedures or infusions are added later, revisit facility, safety, and regulatory requirements before expansion.

Compliance and Referral Development

Pulmonary practice compliance spans HIPAA, documentation, testing quality, billing, prior authorization, marketing, hospital relationships, and professional liability. Policies need to be operationalized through training, audits, and physician-led corrective action.

Referral growth depends on speed, communication, and clinical reliability. Primary care, hospitals, cardiology, oncology, ENT, and rehabilitation programs need timely consult notes, test interpretations, and clear escalation pathways.

Audit referrals, scheduling lag, no-show rates, PFT quality, authorization turnaround, results communication, denials, and adverse events. This data helps protect patient safety while improving the practice experience.

• ✓Maintain HIPAA, billing, incident, and results-management policies.
• ✓Audit PFT quality and interpretation documentation.
• ✓Create referral communication standards for primary care and hospitals.
• ✓Review ownership and financial relationships with healthcare counsel.