Pediatric Coding Alert

You may scoff at taking the time to bill for nebulizer supply codes that reimburse about $1, but the pennies add up. Although nebulizer drug (J7618-J7619, J7644) and medical supply (A7003, A7005, A7015) codes may not pay a lot, you should take the time to bill for these extra items, if the payer permits it.

Pediatricians often underutilize the HCPCS Codes (Healthcare Common Procedure Coding System) Level II codes. But, the alphanumerical national codes, which Medicare, Medicaid and most private payers require, allow physicians to capture reimbursement for office supplies.

Despite the coding system, some coders wonder whether carriers really reimburse for supply codes billed with nebulizer treatments. Most insurers pay for J7619 (Albuterol, all formulations including separated isomers, inhalation solution administered through DME, unit dose, per 1 mg [Albuterol] or per 0.5 mg [Levalbuterol]), says Valerie Frederick, president/owner of Physicians Services, a medical billing service in Cumming, Ga., whose clients include Ivy Ridge Pediatrics, a busy one-physician practice in Cumming. "Carriers pay a very low amount (approximately 10 percent of our charge)." But Frederick admits, "Alittle is better than nothing." At least the reimbursement covers the cost.

So, now that you're convinced that you should bill for pennies, how do you do it? (For a complete list of applicable codes and reimbursement, see "Check Out the Nebulizer Supplies Coding Cheat Sheets" in article 2.)

Report Drug With a J Code

You should bill for the medication used in the inhaler with the appropriate HCPCS J code, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

Common drugs used in a nebulizer include various forms of albuterol (Ventolin, Proventil) and levalbuterol (Xopenex). Select the supply code based on the medication's form. For concentrated forms, assign J7618 (Albuterol, all formulations including separated isomers, inhalation solution administered through DME, concentrated form, per 1 mg [Albuterol] or per 0.5 mg [Levalbuterol]), says Angela L. Mohun, CPC, a coder/trainer for Physicians Associates, an 80-physician group practice serving adults and children in Central Florida. For premixed or unit-dose forms, report J7619.

"Depending on how many treatments the pediatrician provides, bill the J codes in units as well," Mohun says. For J7618 and J7619, you should bill 1 unit per 1 milligram of albuterol and 2 units per 1 milligram of levalbuterol.

For instance, a pediatrician administers two inhalation treatments (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]) containing concentrated albuterol. Report J7618 x 2, one unit per 1 milligram concentrated dose. If the pediatrician used the unit-dose form of albuterol, you should bill J7619 x 2.

When the doctor uses a "concentrated form" of an inhalation drug, you should bill separately for the saline solution (A7019, Saline solution, per 10 ml, metered dose dispenser, for use with inhalation drugs; J7051, Sterile saline or water, up to 5cc) used to dilute it, says Jeremy D. Nelson (www.medicare-solutions.com), the marketing director for My Billing Service, a billing management company in Greenville, Texas.

If you use a unit-dose form, such as Atrovent (J7644, Ipratropium bromide, inhalation solution administered through DME, unit-dose form, per mg) or Xopenex (levalbuterol, J7619), do not charge for the saline separately, Mohun cautions.

Assign 'A'for Accessories

You should report materials used during nebulizer sessions to private payers that may reimburse for these items. Common supplies include an administration set, which includes the lid, jar, baffles, tubing, T-piece and mouthpiece, according to Cigna's Medicare Part B local medical review policy covering region D, which includes Alabama, Arizona, California, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming. For an administration set, select the appropriate code based on the equipment type:
 

The set does not include a mask. If one is required, you should report it with HCPCS supply code A7015 (Aerosol mask, used with DME nebulizer).

Medicare does not reimburse for physician-supplied materials, and you should not report these items to the carrier. "Reimbursement may be made for the replacement of essential accessories such as hoses, tubing, mouth pieces, etc., for necessary DME (durable medical equipment) only if the beneficiary owns or is purchasing the equipment," according to the Medicare Carriers Manual, section 2100.5. Although pediatricians rarely have patients on Medicare, if they do, the pediatrician's office should not report materials to Medicare.