Medicare Compliance & Reimbursement

Tip: Use a judicious mix of modifiers if you have the documentation to back your claim.

You don’t need to leave dollars on the table just because some payers deny payment when your provider spends time helping a patient with an inhaler demo or evaluation. But you’ll need to keep track of the device used, whether medicine was administered during the teaching session, and above all National Correct Coding Initiative (NCCI) bundles before you code.

1. Categorize the Diskus Correctly

Many Part B offices use the Advair Diskus for their patients, which is an aerosol generator. These devices produce airborne suspensions of small particles for inhalation therapy. If the nurse or medical assistant teaches someone to use an Advair Diskus — or any other metered dose inhaler (MDI) — you should report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

Example: The physician starts a patient with asthma (493.00, Extrinsic asthma; unspecified or 493.20, Chronic obstructive asthma; unspecified) on Advair. A nurse then teaches the patient how to use the Diskus. According to CPT® guidelines, you should report 99201-99215 for the office visit (depending on whether you’re treating a new or established patient). Then report 94664 as well.

Append Modifier 25: Because code 94664 doesn’t have a global period, many insurers don’t require you to 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 you’re reporting these services together. However, some payers have begun denying claims for these services when billed together without modifier 25. Therefore, you should typically append modifier 25 to the applicable E/M code when reporting these services on the same date of service. For instance, in this scenario you’d report 99214-25 followed by 94664.

2. Include Treatment in Teaching Session

You might administer a medication dose during the teaching session. If so, remember that both services (treatment and teaching) are bundled into 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]). Because of this, you’ll only report 94640 since the physician performed the administration as part of the demonstration/evaluation.

In black and white: The National Correct Coding Initiative (NCCI) bundles 94664 into 94640. In some cases, you could potentially append modifier 59 to 94664 and report it with 94640, but you typically won’t. Move on to number 3 below to find out when this scenario applies.

3. Remember Modifier 59 for Extra Education

Consider this scenario: An asthmatic patient is wheezing and having difficulty breathing during an outpatient visit. She requires one or more bronchodilator treatments for intervention: 493.02 (Extrinsic asthma; with [acute] exacerbation), 493.21 (Chronic obstructive asthma; with status asthmaticus), or 493.22 (Chronic obstructive asthma; with [acute] exacerbation). During questioning, your physician discovers that the patient didn’t use her MDI device or nebulizer properly prior to her visit. After he treats the patient, he or his nurse provides her with additional education about how to use the devices.

Code it: First, report 94640. If your physician offers multiple treatments, report 94640 the appropriate number of times and append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) to each additional aerosol. For instance, two treatments would be 94640 with 94640-76. Include the appropriate E/M code with modifier 25 appended.

Next, report 94664 with modifier 59 (Distinct procedural service) appended, as the patient required additional instruction for his daily maintenance medication. This is different from the aerosol provided for immediate intervention (94640).

In short: If the patient required separate education after receiving an inhalation treatment on the same day, you would bill both services (treatment and education), appending modifier 59 to 94664.

Logic: The Correct Coding Initiative (CCI) edit on 94640 and 94664 has a “1” in the modifier column, signaling that you can override the edit with the proper modifier. So payers that follow CCI edits will require modifier 59 on the component code (94664) to indicate that the teaching is a distinct procedural service from the inhalation treatment.

4. Prove Medical Necessity

Reporting 94664 can garner almost $19 for your physician, based on the national Medicare non-facility rate payment schedule. Do your part in achieving reimbursement by encouraging physicians to document medical necessity for 94664.

Example: Ask your physicians to document in the plan or treatment portion of the written record that the patient requires a teaching session on the use of his MDI, diskus, nebulizer, etc. In addition, don’t forget to document why the session is necessary, such as concerns with compliance or proper use of the device.

5. Watch Your Supply Billing

If you supply the albuterol for a nebulizer education session, you can report the medication to your insurer (for instance, J7611, Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg).

You typically can’t, however, report the other materials involved in demonstrating nebulizer treatments. These services always uses the tubing (A4616, Tubing [oxygen], per foot]) and mask (A7015, Aerosol mask, used with DME nebulizer), so 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]) includes these supplies.

Incident-to note: Code 94664 59 can be provided by a nurse or medical assistant as an incident-to service directly supervised by the physician. Any time a service can be provided by a member of the practice team, other than the physician, it frees up time the provider can use to see additional patients or complete other patient work.