EM Coding Alert

Question: An established patient comes in for a routine evaluation and management (E/M) visit, where they discussed their concerns about the efficacy of their current asthma prescription with the pulmonologist. The doctor prescribed a new prescription with a Diskus inhaler. The pulmonologist also instructed the patient on how to use the new inhaler.

What are the correct codes to use for this visit?

South Dakota Subscriber

Answer: For the scenario you described, you will use 94664 (Demonstration and/ or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) to code the pulmonologist’s demonstration of the Diskus, which is a metered dose inhaler.

Code 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) may appear like the correct answer as the descriptor refers to treatment with a metered dose inhaler, but the descriptor doesn’t explicitly represent the intent of the service or what occurred.

Code 94640 should be used when the patient is having an acute exacerbation, and the intent of the intervention or medication provided is symptom management. An inhalation treatment could also be used to open the airways of a patient that has pulmonary issues and is having difficulty producing a sputum specimen. The former is most often encountered in the physician’s office. Since the patient’s medication regime was being changed with the amended intervention, the demonstration and education on its use meets the requirements of 94664.

As far as coding the office visit, you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) to reflect the level 3 E/M visit if the physician considers the asthma as stable. Typically, you’ll also append modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) to the E/M code when reporting these services on the same date of services because some private insurers and state Medicaid carriers may deny claims for services when billed together without modifier 25 — but you should check individual payer guidelines for the correct way to bill in this situation.

In summation, this level 3 office visit where the pulmonologist issued a new prescription and demonstrated the use of the Diskus will be coded as 94664 followed by 99213-25.