Pediatric Coding Alert

Although albuterol and levalbuterol J codes have changed, many previous inhalation solution supply "best practices" remain (mostly) the same. Anytime you consider reporting nebulizer medication, follow four guidelines.

Watch out for solutions that use ipratropium bromide. For albuterol mixed with ipratropium bromide, use J7620 (Albuterol, up to 2.5 mg, and ipratropium bromide, up to 0.5 mg, FDA-approved final product, noncompounded, administered through DME) rather than J7611-J7614.

Inhalation solution with only ipratropium bromide falls under J7644 (Ipratropium bromide, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per mg). "We use J7644 for Atrovent," says Christy Neff, RMC, billing specialist for Witham Health Services in Lebanon, Ind.

Codes J7611-J7614, J7620 and J7644 are specifically for noncompounded (premixed) inhalation solutions. For compounded (pharmacy- or office-mixed) solutions, look to:

Warning: Insurers may follow Medicare's lead and not cover compounded solution, which is not FDA-approved. In these cases, you may have to write off the supply cost. Patients who require inhalation treatment for asthma are emergent cases that, due to their clinical nature, may not allow for advance notification and acceptance of financial responsibility or for patient pharmaceutical prescription and purchase.

Before you charge for noncompounded inhalation solution used in inhalation 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]) or continuous inhalation treatment (94644, Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour), make sure your office purchased the supply.

"If we use Xopenex (J7612, J7614), we use our sample supply from Sepracor, so we never charge anyone for it," Neff says.

If a biller tells you there's no reimbursement for J7611-J7614, tell her to ignore the Medicare Physician Fee Schedule's "X"s. For drug payments, you have to look at the Medicare Part B Drugs Average Sales Price (ASP) file available from http://www.cms.hhs.gov/home/medicare.asp.

You can use CMS' ASP rates, which are based on 85 percent of the wholesale rate, to judge if private insurers' payments are appropriate. The CMS ASP pays non-compounded inhalation solution these amounts:

For your purchased supply, check the amount of drug administered through the nebulizer or inhalation machine. "Ask, 'How many mg were given?' " says Denae M. Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw, Mich.

Bookmark: You'll use different equations for albuterol and levalbuterol. For albuterol, you report 1 unit per 1 mg. You should use 1 unit for each 0.5 mg of levalbuterol administered.

Example: A pediatrician evaluates an established patient with shortness of breath (786.05) and wheezing (786.07). A nurse does a pulse oximetry showing hypoxia (799.02, Hypoxemia) and gives a nebulizer treatment of 1 mg concentrated Albuterol. The patient's O₂ reading is still not within normal limits, and the nurse gives another same-dose treatment. The patient's symptoms subside, and a post-aerosol pulse oximetry reading shows that the patient's pulse oxygen saturation level has returned to normal ranges.

For these services, you should report the following:

Dx 1: 786.05

Dx 2: 786.07

Dx 3: 799.02

Breakdown: Because the pediatrician makes no definitive diagnosis, you should link each service and supply code to the symptoms: shortness of breath (786.05), wheezing (786.07) and hypoxemia (799.02). Depending on the insurer's policy, you may need to add modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to show that the office visit (9921x, Office or other outpatient visit for the E/M of a patient ...) is significant and separate from the minor E/M associated with the pulmonary services (94640 and 94761, Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations [e.g., during exercise]).

To indicate the physician had to repeat the nebulizer treatment, use modifier 76 (Repeat procedure or service by same physician) with the second 94640. Because 1 mg equals 1 unit of J7611 and the physician used 2 mgs, you should report 2 units of the albuterol concentrated code.