Pediatric Coding Alert

You'll rethink 94640, 94664-59 thanks to these experts' explanations.

Misinterpreting modifier 59's separate session definition could cause you to unnecessarily bundle nebulizer education with treatment.To stop this $15 payment loss, use these guidelines to start reporting 94664-59 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device; Distinct procedural service) with 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).

Respect This Edit

The Correct Coding Initiative (CCI) places a level one edit on 94640 and 94664. You can use a modifier to override the bundle when unusual circumstances make doing so appropriate.

Impact: Medicare and payers that follow CCI edits may require modifier 59 on the component code (94664) to indicate the teaching is a distinct procedural service from the inhalation treatment (94640). Circumstances that would make modifier 59 appropriate include a different session or different site or organ system not ordinarily encountered or performed together.

Problem: You may have heard that the only time you can report 94640, 94664-59 is when the procedures occur at two encounters, such as treatment in the morning and training in the afternoon. "Some individuals who do not have a clinical background and do not understand the practice operations may misunderstand the 'separate' implication of 59 in this scenario," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Report Post-treatment Training

When education occurs during the treatment, you should bundle 94664 into 94640.

Specifics: "If the nurse (or doctor) reviews the steps of administering the nebulizer treatment during the administration of the nebulizer treatment, then education would be bundled," Pohlig says.

You can, however, report 94664-59 when no education occurs during treatment.

Details: The patient may first receive the treatment, such as via neb or other method, with no education provided. After the treatment, the patient may receive education regarding the type of medication and/or device the patient actually uses or the physician is prescribing.

Rethink 'Separate'

The education in the above scenario meets modifier 59's definition for two reasons:

1. The education is a separate session from the treatment even though it still occurs at the same visit. "Separate sessions can be sequential without much time between them," explains Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

2. The education may involve a different medication. "The medication used in the treatment could have been a 'rescue' medication, not the maintenance medication administered in a different format that the patient uses on a daily basis," Pohlig explains.

Test: Spot Different Sessions

See if you can tell where treatment stops and an education session begins in this clinical example describing a physician's effort in a busy office.

What happens: A patient, who is scheduled for an outpatient visit, comes into the office wheezing and short of breath. The physician sees the patient briefly and decides the patient needs a nebulized bronchodilator treatment that is delivered through a powered nebulizer using an albuterol solution, Plummer says. "If the patient improves significantly after the first treatment (94640), then the office visit is" completed with the physician (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient; plus, when payer required, modifier 25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) who will find out why the patient is wheezing, Plummer says. "If not, one or multiple treatments are given (94640-76, Repeat procedure or service by same physician)." "If the physician feels the patient has not been using an MDI or other inhaler properly, then either he or his nurse will instruct the patient," Plummer continues. "This is a separate session from the original nebulizer treatment," which you would bill as 94664-59.