Pediatric Coding Alert

In the April 2000 issue of Pediatric Coding Alert, we covered the difference between 94640 (nonpressurized inhalation treatment for acute airway obstruction) and 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) and 94665 (subsequent). The main difference is that 94640 is used when you provide treatment, as in the case of nebulizer for a patient with asthma, and 94664/94665 are for teaching the patient (or parent) how to use the nebulizer. This had not previously been clear, and our investigation led to a clarification that was published in the April issue of CPT Assistant. (See Optimize Reimbursement for Nebulizer Encounters With Proper Coding on page 25 of Pediatric Coding Alert, April 2000.)

Also in the April issue of CPT Assistant, it states that code 94664 does not include the services described in 94640. That means that you should report both 94640 and 94664 or 94665 if you provide treatment and education.

We confirmed this with Walter ODonohue Jr., MD, FCCP, CPT Codes advisor for the American College of Chest Physicians (ACCP) and chair of the CPT relative update committee (RUC) for the ACCP. If you gave a treatment, and then you instructed the patient in the use of the nebulizer, you should use both 94640 and 94664 or 94665, says ODonohue, who is also associate dean of graduate medical education at Creighton University in Omaha, Neb. ODonohue notes that many insurance companies will be confused by this and wont want to pay both codes. To make the payers understand that two separate services were provided, he recommends the use of modifier -59 (distinct procedural service) on one of the two codes. If a child needs more than one treatment in one day, you should use 94640 for each treatment, with a modifier -76 (repeat procedure by same physician) on the subsequent treatment.

Pediatricians often wonder how many times 94664 can be useddoes initial mean once per lifetime, once per year, once per day? ODonohue says that although it usually means once per lifetime, there are circumstances under which you could use it more than once. For example, you instruct the patient on the use of a hand-held nebulizer for the first time, and bill 94664. Then, if you instruct the same patient a month later on the use of a small-volume nebulizer, you could code 94664 again, says ODonohue, because youre providing instruction on a different device. If the insurance company denies your claim because it will pay only once per lifetime, you will need to refile it with a note explaining that the instruction was provided on a small-volume nebulizer the second time, and a hand-held nebulizer the first time, says ODonohue.

Another circumstance in which it would be permissible to use 94664 twice is if the childs mother is instructed on the use of the nebulizer, and a month later the child is brought in by the grandmother because the parents are away, and the grandmother needs instruction.

For all other education encounters, use code 94665.