Internal Medicine Coding Alert

Tackle common coding problems with our case studies

Does your internist treat respiratory conditions, such as asthma and emphysema? If so, you should know how to report nebulizer treatments, respiratory drugs, and the appropriate E/M services.
 
To familiarize yourself with some basics of nebulizer coding, use the following expert-approved case studies.

Get Ready for J-Code Bundles

Case study #1: A patient presents with acute exacerbation of asthma (493.02, Extrinsic asthma; with [acute] exacerbation). The nurse, who's working under the internist's supervision, administers albuterol using a pressurized inhalation treatment.
 
What to report: You should assign 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device) for the nebulizer treatment, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, NJ.
 
To bill for the drug, list the appropriate J code, such as J7619 (Albuterol, all formulations including separated isomers, inhalation solution administered through DME, unit dose, per 1 mg [Albuterol] or per 0.5 mg [Levalbuterol]).
 
Warning: Don't expect most Medicare carriers to pay for J7619 when you report it in addition to 94640, says Roxann Zellers, CPC, a coding and reimbursement specialist for the Rockford Clinic in Illinois. Medicare considers 94640's reimbursement to cover the drug charge. Private insurers may pay separately for the drug, she adds.
 
Heads-up: To get paid under this circumstance, you'd have to ensure the visit meets "incident-to" billing requirements, because the nurse, not the physician, provided the nebulizer treatment. This means that the supervising internist must be physically present in the same office suite and immediately available to assist if necessary.
 
Case study #2: An established patient with emphysema (492.0, Emphysematous bleb) comes into the office for shortness of breath (786.05). The internist provides inhalation treatment and then trains the patient on how to use the nebulizer at home. The physician also provides an expanded problem-focused examination and medical decision-making of low complexity.
 
What to report: The correct code for the nebulizer training is 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device), Brink says.
 
But you should bill 94664 along with 94640 on the same day to Medicare only if the 94664 is distinct from the treatment, Zellers says. In this case, attach modifier -59 (Distinct procedural service) to 94664, she adds.
 
On the other hand, a private carrier may allow you to assign 94640 and 94664 without a modifier if the carrier doesn't follow the National Correct Coding Initiative (NCCI) guidelines.

Remember Your E/M Charges

Because the physician also performed an office visit, you should report 99213 (Office or other outpatient visit for the E/M of an established patient). Remember to attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, if the E/M is "separately identifiable," Zeller says. The modifier unbundles the E/M code from 94640.
 
Tip: Not all payers require this, but you can support your case for unbundling 99213 if you link separate diagnosis codes to the E/M and the nebulizer treatment. For instance, you could link 786.05 (Shortness of breath) to 99213, and link the emphysema code (492.0) to 94640.

Training Alone Means 1 Code

Case Study #3: Your nurse provides nebulizer training to an established patient who has acute bronchitis (466.0). The primary reason for the visit was the training. The nurse performs no other procedures or services.
 
What to report: In this case, you should report only 94664, but not an E/M code (99201-99215). That's because the patient presented to the office for training on how to use the nebulizer and did not receive any further evaluation or treatment.