Pediatric Coding Alert

If denials for nebulizer training with treatment stump you, get a grasp on what you should expect from 94664-94640 claims with the following answers to your top coding questions.

1. How Should You Code for Treatment, Training?

Although payment variations exist on claims containing same-session nebulizer treatments and training, you may report CPT 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) in addition to 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]), based on CPT. Codes 94640 and 94664 describe separate services, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "Code 94664 is an instruction session so the patient can perform this service himself," she says. "It is not part of the treatment (94640)."

2. Why Do Insurers Bundle These Codes?

Even though CPT makes treatment and training separate services, some payers bundle 94664 into 94640 based on coding edits. For instance, Medicare's National Correct Coding Initiative bundles the training (94664) with a treatment (94640), says Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a premier medical billing company in Lakewood, N.J. If a private insurer adopts Medicare's policies, the payer may include 94664 with 94640. 
 
One insurer that recently (Oct. 13, 2003) implemented a nebulizer training edit is Aetna US Healthcare Georgia, says Valerie Frederick, president of Physician Services, a medical billing firm in Cumming, Ga., whose clients include Ivy Ridge Pediatrics. Aetna US Healthcare's agreement with the primary physicians in The Children's Healthcare Network of Georgia states that it will remove 94664 and 94665 (previously deleted code) from its coverage and add 94640, which it will reimburse at $36.75. Prior to the policy change, Aetna paid $35.70 for 94664 and fee for service for 94640, she says. "Now the insurer will pay only $36.75 for 94640 with 94664 bundled into 94640."
 
Another reason that some payers deny 94664 is capitation plans. Under these arrangements, the insurer may include training payment as part of the capitation. For instance, Horizon Mercy Health Care in New Jersey denies 94664 stating, "The service is covered under capitation."

3. Where Are Denials Most Prevalent?

Not all pediatric practices struggle with 94664 rejections. Coverage varies based on payer, as well as region. Denials seem frequent in the East and the South.
 
But Midwest pediatricians don't encounter many rejections. "My coder says we haven't had any 94664-with-94640 reimbursement problems," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio.
 
4. Who Is Denying Training?

If you're wondering which insurers are denying 94664, here are a few, see table this article.


5. What Can You Do About Rejections?

Depending on the denial reason, you may still have some chances to recoup training dollars. Coding experts recommend these strategies:

  If an insurer bundles 94664 into 94640 based on coding edits, you may include face-to-face training time in the E/M service, Cobuzzi says.

  For capitation plans that include training, try to renegotiate for separate payment at renewal time.

  When a payer doesn't pay for training with treatment, appeal the decision if the insurer's policy doesn't include 94664 with 94640, Frederick says. Explain to the representative that 94664 is a separate service from 94640. CPT 2003 revised these codes, and some insurers may not understand the services the codes describe. If you don't receive payment with these actions, file a quality-assurance complaint with your regional medical director.