Pediatric Coding Alert

Find out if your coding knowledge needs to be modified.

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below:

Answer 1: CPT^® guidelines prohibit you from coding 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) with four other CPT^® codes:

• 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration)
• 94070 (Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents (eg, antigen[s], cold air, methacholine))
• 94400 (Breathing response to CO2 (CO2 response curve)).

However, all of these codes have a modifier indicator of 1, meaning that when either of the codes are column 1 codes in an edit pair with 94640 as the column 2 code of the edit pair, you can unbundle the services with a National Correct Coding Initiative- (NCCI-) associated modifier. Depending on the payer, that could be either modifier 59 (Distinct procedural service) or modifier XU (Unusual non-overlapping service …), which you would append to the column 2 code — in other words, the 94640.

“There are, however, a handful of CPT^® codes identified by NCCI edits for which a CPT^® code cannot be billed with CPT^® 94640,” says Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts. They are:

• 36591 (Collection of blood specimen from a completely implantable venous access device)
• 36592 (Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified)
• 89220 (Sputum, obtaining specimen, aerosol induced technique (separate procedure))
• 96523 (Irrigation of implanted venous access device for drug delivery systems).

“For these codes, there are no circumstances in which both procedures should be paid for the same beneficiary on the same day by the same provider. This is identified in NCCI with modifier indicator 0,” Walaszek advises.

Don’t forget. “Documentation of any of the codes listed will be essential to justify that the service was performed,” notes Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “Likewise, you should also document and bill for medications and supplies, so be certain to add the appropriate HCPCS J codes for medications as well as the applicable supply codes from the A codes,” Holle adds.

Answer 2: In this particular case, you cannot use 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour); first, because the treatments are not continuous as indicated by the code’s descriptor, and second because each individual treatment lasts under an hour. So, coding the encounter as 94644 with +94645 (…; each additional hour (List separately in addition to code for primary procedure) would be incorrect in this case.

Instead, “if the medical record documentation reflects that the patient had, for example, one episode of care in the morning and received an inhalation treatment of 55 minutes, including start and stop times, and after being

discharged, the same patient returned to the clinic later that day due to continued breathing problems and received a second inhalation treatment of 55 minutes, including start and stop times, you will then bill 94640 and 94640-76 [Repeat procedure or service by same physician or other qualified health care professional], since this would be a separate ‘episode of care’ as defined by CMS [the Centers for Medicare & Medicaid Services],” notes Walaszek.

Pro coding tip: Don’t forget that, “in addition to the inhalation treatments, appropriate medication and potentially an evaluation and management [E/M] service with modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service] may be billed separately,” Walaszek reminds coders. Additionally, “it’s a good idea,

when possible and applicable, to use separate diagnosis codes for the visit as well as the treatments,” says Holle.

Answer 3: “CPT^® codes 94640 and CPT^® code 94664 [Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device] generally should not be reported for the same patient encounter/episode of care,” cautions Walaszek. But, as with answer one of this quiz, you will have to make sure that you closely follow NCCI guidelines.

NCCI has created another edit pair when 94664 is the column 2 code to 94640, meaning that the treatment is

bundled into the demonstration. However, NCCI has also given this pair a modifier indicator of 1, so the pair can be unbundled using an NCCI-associated modifier. Again, depending on the payer, that would be either modifier 59 or XU, which you would use on the 94664.

Coding alert: Again, in order to separate both services, documentation will be key. “Only when the teaching piece of the visit is performed after any treatment, and only when the teaching is justified and documented, can the 94664 be billed,” notes Holle.