Pediatric Coding Alert

Stop missing opportunities to capture $15 for 94664 -- or coding it when you shouldn't -- by getting the lowdown on the pulmonary service's qualifying devices, documentation requirements and payment obstacles.

Should you use 94664 for education/training with the Advair Diskus? asks Jen Krohn, CPC, CCP, coding specialist at Waukesha Health Care Inc. in Wisconsin. "Our allergist says no, but our pediatricians say yes."

Pediatric Coding Alert went straight to the experts to find out. Code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) "would seem appropriate to use for [Advair Diskus] demonstration and evaluation," says Gary N. Gross, MD, executive vice president of the Joint Council of Allergy, Asthma & Immunology.

Why: The Advair Diskus is an "aerosol generator," says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. Therefore, "teaching someone to use an Advair (or any other) diskus does fall under 94664."

Example: A pediatrician starts a patient with asthma (493.00, Extrinsic asthma; unspecified) on Advair. A nurse then teaches the patient how to use the diskus. You should report 99201-99215 for the office visit and 94664 without a modifier, according to CPT guidelines, Plummer says. CMS transmittal R954CP also indicates that modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) applies only to E/M services performed with procedures that carry a global fee, which 94664 does not have.

Beware: Before dropping 25 from 99201-99215 with 94664, check with your major insurers. "Some payers may require modifier 25 appended to the E/M when performed with 94664 or any 'pulmonary' service," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

This increasingly common use of modifier 25 is acceptable if the payer requires it. Get this requirement in writing or e-mail from the payer.

During the teaching, the patient may receive a medication dose. In this case, Pohlig says, you should not separately report the treatment (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]).

Reason: The administration "was performed as part of the demonstration/evaluation, and the service's intent was patient teaching," Pohlig says.

But if the reverse occurs and the patient requires separate education after receiving an inhalation treatment, you may be able to bill both services.

"Typically, code 94640 does not include patient education," writes Steve G. Peters, MD, FCCP, in "Continuous Bronchodilator Therapy" published in the American College of Chest Physicians' Chest (2007; 131; 286-289). "If separate medication instruction occurs on the same day as an initial aerosol treatment (e.g., a different form of inhaler requiring education), code 94664 can be used with a 59 modifier to indicate the distinct procedural service," explains Peters, of the department of internal medicine, Division of Pulmonary and Critical Care Medicine at the Mayo Clinic in Rochester, Minn.