Pediatric Coding Alert

Albuterol, a bronchodilator added to saline and nebulized to treat asthma attacks, isnt expensive. Rocephin, a powerful antibiotic used for severe infections, is expensive. Both of these medications are used commonly in pediatrics. And both involve procedure codes on top of office visit codes, and supply codes as well. What are the best ways to code for administering these medications, bearing in mind that expensive or not, you need to recoup your cost?

Coding for Initial Albuterol Treatment

When you give albuterol by nebulizer, there are two procedure codes you need to be concerned about: CPT 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) and 94665 (subsequent).

The first question coders have is, What does initial mean? Because this isnt defined in CPT, insurance companies are interpreting it the way they want to. It should mean the first treatment on a given day, says Keisha Gregory, reimbursement and coding analyst for Practice Solutions, a billing company which specializes in pediatrics in Durham, NC. For her clients, Gregory bills for one unit of 94664, and the number of units of 94665 needed to be done in the case of multiple treatments during a visit. But not all providers are this lucky.

If you are in a state like Florida or California, where managed care is extremely restrictive, you may find companiesand even the governmentdefining initial as being relatively rare. We can only bill 94664 once every six months, says Carmen Cortes, billing coordinator for Island Coast Pediatrics, a six-pediatrician practice in Cape Coral, FL. The six-month guideline is dictated by Medicaid, says Cortes, who follows this guideline for all payers.

The Solution: 94640

It must be remembered that some insurance plans will only pay for 94664 once in a lifetime. Some offer only a trivial reimbursement for 94665. One alternative is to use 94640 (non-pressurized inhalation treatment for acute airway obstruction) for each treatment, according to Thomas Kent, CMM, former office manager of a pediatric practice and principal of Kent Medical Management in Dunkirk, MD. While the reimbursement for 94640 is a little less than 94664, it is significantly greater than 94665, says Kent. So you can use 94640 for each treatment. For example, if a child receives three nebulizer treatments on the same day, you would list 94640 with three units. You also would use an office visit code with the nebulizer codes, says Cortes.

In fact, the definition of 94640 is a more accurate description of the care given to asthma patients by pediatricians, says Kent. While the allergist will provide inhalation treatment for non-acute patients, the pediatrician nearly always is treating acute asthma.

Billing for Supplies

Cortes doesnt worry about charging for the supply. In fact, many practices arent concerned about getting reimbursed for the albuterol because it is so inexpensive. It costs about 30 cents per treatment.

However, if you do a lot of nebulizer treatments, and have a philosophy of trying to collect every penny, these are the codes to use: J7620 (0.083%) and J7625 (0.5%) for the solution being administered. There are also K0504 and K0505.

What is the difference between the J and K codes for albuterol? The two K codes are for the different versions of albuterol. The K codes are a temporary category; new codes appear here for a year or two while HCFA tries them outsometimes they are deleted, but more often they are moved to a permanent category. The code K0504 is for a bottle of albuterol concentrate with a dropper. Sterile saline is placed in the nebulizer with the proper number of drops as directed by the physician.

This should be billed per milligram used. The code K0505 is for albuterol packaged in small vials with the proper dose premeasured. The two J codes are for plastic vials containing albuterol premixed in sterile saline at the desired dosage. You would code for the supply depending on what method you use. At Kents practice, he did not bill for albuterol because they received it from the drug company representative for free.

Gregory notes that commercial insurance companies pay the nebulizer code well enough so that it isnt necessary to bill for the albuterol. But Medicaid doesnt pay well, and they still wont let you bill for the medication. (Medicare carriers view the albuterol as an integral part of the nebulizer code and, therefore, will not allow you to bill for it. Many Medicaid plans are taking the same route.)

A final note on 94664/94665: Sometimes the CPT definition confuses coders, who think that aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes means that the procedure is done for diagnostic purposes. But in reading CPT, you have to think like a lawyer: Pay close attention to the punctuation.

When performed for sputum mobilization or bronchodilation, 94664/94665 is for therapeutic purposes. When performed for sputum induction, 94664/94665 is for diagnostic purposes: You want a sputum specimen. In practice, these lines may be blurred sometimes. But because there is no comma between sputum induction and for diagnostic purposes, that means that for diagnostic purposes applies only to sputum induction, not sputum mobilization or bronchodilation.

Billing Rocephin: Dont Forget Injection
and Supply Codes

Rocephin costs over $25 for a 500-milligram dosenot something you want to give away. And unfortunately, some insurance companies are not paying for Rocephin.
So you need to make sure you are coding the rest of the visit optimally.

Probably the biggest mistake practices make when it comes to injecting Rocephin is not billing all the codes you can: office visit (99212-99215 for established patient), injection (90788), and supply (J0696).

We bill the office visit, the injection code, and the J code, says Cortes. But some companies still wont pay for the antibiotic, however, so we tell the parent that they may have to pay. Its important to convey this information to the parents so they are not shocked when they get a bill, says Cortes, noting that parents accept the pediatricians recommendation when their child needs this drug.

Note: The J code for Rocephin is per 250 milligrams, and the drug is given in varying amounts according to the childs weight. Use units to indicate each 250-milligram portion administered.

Richard H. Tuck, MD, FAAP notes that administering Rocephin does involve extra worknot just the nurse giving the injection. You need to talk to the family, and observe the child for a reaction, says Tuck, who practices with PrimeCare Pediatrics in Zanesville, OH. Tuck also notes that insurance companies should pay for Rocephinit saves them money. Before Rocephin, many of these children used to have to be admitted for intravenous antibiotics, he says. Now, we can give the shot in the office. Tuck agrees that the visit should be billable as the injection (90788) and the supply (J0696), as well as the office visit.

Every office should get reimbursed for Rocephin, says Tuck. If they cant get the insurance company to reimburse them for the injection given in the office, they should write a prescription. Then the parent can go to the pharmacy and pick it up and bring it back to the office, where the medication can be administered. The medication will then be billed to the patients pharmacy benefit. The obvious drawback of this method is if the child is very sick and there is no pharmacy nearby. In that case, notes Tuck, you wouldnt want to send the parent and child all over town to get and wait for the medication. In our case, we have a pharmacy which is nearby, he says.