Otolaryngology Coding Alert

Question: When I bill two units of 94640, insurers deny the second charge. What am I doing wrong?

Delaware Subscriber

Answer: Instead of billing two units of 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]), the CPT manual instructs you to append modifier 76 (Repeat procedure or service by same physician) for more than one inhalation treatment performed on the same date.

If your payer denies the charge with modifier 76, appeal with the CPT manual instructions. If you find that you appeal continually, try to get a meeting with the medical director. You may find that this is an uphill battle as some payers, including some MACs, dont process modifiers 76 and 77 (Repeat procedure by another physician) correctly. They only allow the payment for these modifiers on diagnostic procedures such as radiology, and not for therapeutic procedures. It is difficult to get a payer to make these systemic changes. When this happens, you may have to append modifier 59 (Distinct procedural service) the second time you perform the treatment. You want to avoid modifier 59, as using it too often may raise red flags and you want to use more appropriate modifiers whenever possible.

Dont forget: For the inhalation medicine, report two units of the appropriate solution, such as J7613 (Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 1 mg). Because J7613 represents one unit dose, you should report per nebulizer treatment or, in our example, J7613 x 2.