Pediatric Coding Alert

and one service:

Coverage for pulse oximetry (94760, Noninvasive ear or pulse oximetry for oxygen saturation; single determination) depends on the payer. Medicare announced in January 2000 that it would no longer cover 94760 unless it is the only procedure provided. This means that if you bill any other code on that day, you cannot bill pulse oximetry as well because Medicare has bundled the oximetry codes into every other CPT code. If you perform pulse oximetry and nothing else, that is the only time you can bill and get paid for this procedure.

Carriers view pulse oximetry as similar to taking a patient's temperature. "Pulse oximetry is no more invasive and arguably less invasive than recording the patient's temperature, another example of a diagnostic service for which we do not make separate payment," according to Medicare's announcement. "If interpretation of pulse oximetry or temperature data is complex, then that interpretation is clearly part of the medical decision-making included in the E/M services," the notice states. And finally, Medicare states that facility and practice expense payments cover the equipment costs.

Since then, various commercial payers have followed Medicare's lead. Some carriers, however, do not bundle 94760 with other codes, so you can bill for it separately. For the above scenario, report 94760 x 2.

Consequently, you should track commercial payers who bundle the code and write off the charge before it goes out the door. Make sure to keep the code on your superbill and put it on the claim form as well.

For the spirometry before and after bronchodilation, report 94060 (Bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]). Bronchospasm evaluation describes the evaluation and respiratory function measuring (spirometry), and thus includes spirometry before and after bronchodilation. You should not bill separately for 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). Note that 94010 specifies that the spirometer must display results graphically, which also applies to 94060. Assign 94060 for each before and after reading.

In addition, you should report the individual spirometry reading that the pediatrician performs after the second inhalation treatment. For the reading, assign 94010. The doctor takes a spirometric reading after administering the inhaler only. So, you should report 94010 rather than 94060.

To code for the spirometry before and after bronchodi-lation, combine the spirometry and bronchospasm evaluation and report 94060. You should also report 94010 for the stand-alone spirometric reading.

For each inhalation treatment, report 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]), says Charles A. Scott, MD, FAAP, a pediatrician at Medford Pediatric and Adolescent Medicine in Medford, N.J. "Use the nebulizer code 94640 each time you use the nebulizer." Repeat inhalation treatments may require a modifier as described below.

Some coders mistakenly include additional services, such as spirometry and training, in 94640. CPT Assistant, April 2000, clearly states, "94640 is reported for an inhalation treatment for an acute airway obstruction, such as asthma or croup, and can represent an aerosol or nebulized administration of the appropriate medication, as prescribed by the physician."

Spirometry and inhalation treatment are different procedures performed for different reasons. You should report both procedures, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. Spirometry is diagnostic, and inhalation treatment is therapeutic.

However, you may run into problems reporting both procedures. The Correct Coding Initiative (CCI) bundles 94640 into 94060. Medicare interprets 94060's definition of pre- and postbronchodilation as a global code, meaning the bronchospasm evaluation includes the inhalation treatment. For payers who follow Medicare's lead and CCI edits, you cannot report 94640 with 94060. If the pediatrician performs both, bill 94060, which has a higher relative work value.

"Bundling issues are payer-specific," Callaway says. So, don't stop reporting the treatment until you review your carriers' policies. Submit claims with both procedures. When you receive the explanation of benefits, note the insurers' payments and track their preferences so you can tell which rules the insurer follows.

If a payer includes the inhalation treatment in the bronchospasm evaluation, remember that you can still report these procedures if the physician performs them at different sessions. For instance, the child in the above scenario returns to the pediatrician's office later the same day because he cannot use the at-home treatment and has an acute exacerbation. The pediatrician performs a nebulizer treatment. Report 94640 for the inhalation treatment appended with modifier -59 (Distinct procedural service) to indicate a separate session from the spirometry that he performed earlier. Although the carrier may bundle 94060 and 94640 when the doctor performs them together, you can still report them when he or she performs them at separate sessions.

Practices report varying success in reporting multiple treatments. But according to CPT 2003, "For more than one inhalation treatment performed on the same date, append modifier -76 [Repeat procedure by same physician]." Some carriers may prefer you to bill nebulizer treatments per unit, as suggested in Coding for Pediatrics 2003: "Bill the number of 'unit' if more than one treatment is needed for response." To complicate issues, some coding experts report needing to use modifier -51 (Multiple procedures) for payment of multiple nebulizer treatments. Remember that -51 will reduce the second procedure by 50 percent based on standard multiple-procedure rules. CPT 2003's directive may help payers recognize modifier -76, but you should still follow individual carrier's recommendations.

Based on these recommendations for the two inhalation treatments, you could report, based on payer:

Or, if the carrier follows CCI, you may report 94060 only and not 94640.