Otolaryngology Coding Alert

These 3 case studies will illuminate key coding concepts.

If your allergist treats respiratory conditions such as asthma and emphysema, you'll need to bone up on coding for 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.

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 allergist'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.

To bill for the drug, list the appropriate J code, such as J7613 (Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg).

Warning: Don't expect most Medicare carriers to pay for J7613 when you report it with 94640. Medicare considers 94640's reimbursement to cover the drug charge. Private insurers may pay separately for the drug.

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 a supervising allergist must be physically present in the same office suite and immediately available to assist if necessary. The physician also has to have developed the patient's plan of care. The supervising physician (physician present in the office suite) does not have to be the patient's regular allergist.

Case study #2: An established patient with emphysema (492.0, Emphysematous bleb) comes into the office for shortness of breath (786.05). The allergist 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).

But you should bill 94664 along with 94640 on the same day to Medicare only if the 94664 is distinct from the treatment. In this case, attach modifier-59 (Distinct procedural service) to 94664.

On the other hand, a private payer may allow you to assign 94640 and 94664 without a modifier if the payer doesn't follow the Correct Coding Initiative (CCI) guidelines and does not bundle 94640 and 94664.

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). Because 94640 and 94664 have xxx global days, it may or may not necessary to attach a 25 modifier to the E/M service. This will depend on the payer's or carrier's interpretation of the Correct Coding Initiative (CCI) and the global definition of an xxx global period procedure. By AMA definition, xxx global period procedures do not have any E/M associated with them. But CCI version 7.2's verbiage added the definition that xxx global period procedures would be considered to have the same small E/M service associated to them as minor procedures do by definition. After the publication of the V7.2 CCI, some payers require the provider to attach modifier 25 (Significant, separately identifiable E/M 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" and some payers do not require modifier 25. When required, the modifier unbundles the E/M code from 94640.

Tip: Even though not all payers require this, it is still a good idea to support your case for unbundling 99213 from your procedures 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 report the emphysema code (492.0) with 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), because the patient presented to the office for training on how to use the nebulizer and did not receive any further evaluation or treatment. Additionally, since the patient did not receive a treatment, do not report 94640 in addition to 94664.