Pediatric Coding Alert

And two services:

Note: For a detailed description of this session, see January's Pediatric Coding Alert, page 1.

Many pediatricians question whether the nebulizer 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]) includes training on the inhaler. Code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) is not a treatment, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "It is an instruction session so the patient can perform this service himself."

Much of this confusion stems from the earlier definitions of 94664 (Aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) and 94665 ( subsequent) clarified in CPT 2003. The helpful language eliminates the term "initial" and adds "patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device." In addition, CPT eliminated 94665. These changes clarify that 94664 refers to an inhaler demonstration. "Code 94664 does not include the services described by code 94640," states CPTAssistant, April 2000.

For the nurse training, you should report 94664. The 2003 National Physician Fee Schedule Relative Value File requires direct physician supervision for 94664. If the office staff demonstrate how to use the nebulizer under direct supervision, use 94664 rather than 99211 (Established patient office visit ...) says Victoria S. Jackson, chief executive officer of Southern Orange County Pediatric Associates and owner of Omni Management, which provides practice management services for 15 medical offices in the Los Angeles area.

To meet direct-supervision requirements, the pediatrician must be physically present in the same office suite and immediately available to render assistance if necessary.

Individual payer policies may cause many pediatricians to think that 94640 includes the training. CCI bundles nebulizer training (94664) into the bronchospasm evaluation (94060). So some practices may receive denials for 94664 from payers who follow CCI edits.

In addition, some third-party payers allow 94664 once per year. But this ruling reflects 94664's prior definition of an "initial" training session. Hopefully, CPT 2003's deletion of 94665 and the term "initial" from 94664 will clarify that 94664 applies per training day.

For carriers that bundle the training or add other exclusions, such as one training per year, you should aggressively appeal these edits based on the newly defined CPT codes, says Richard H. Tuck, MD, FAAP, medical director of quality care partners, PrimeCare of Southeastern Ohio in Zanesville. "You should challenge any carrier that bundles the initial training or the treatment as inclusive in the E/M service."

For the training, applicable codes include:

You will often report an E/M in addition to 94060, Callaway says. If the office visit is to review the set of problems, and the airway function evaluation is to assess the severity of the problem, you should report both the service and the procedure. "The E/M is looking at the whole picture of the patient in the context of the problem," she explains. "Code 94060 is quantifying a particular issue for the physician."

Most payers require you to append the E/M code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate a separate E/M service from the nebulizer treatment, Callaway says. Some payers may not require modifier -25, making billing for these services easier. Therefore, know your payers and their policies.

For some carriers, you can report the procedures appended with modifier -59 (Distinct procedural service) and the E/M without a modifier. "The patient came in for the visit, not the spirometry and inhalation treatment," Jackson says. Modifier -59 appended to the spirometry and inhalation treatment appropriately describes the procedures as distinct procedural services from the E/M.

For the pediatrician's history, evaluation and medical decision-making, you should report the appropriate-level E/M service (99212-99215, Established patient office visit). Include the physician's work performed before and after each bronchodilation, says Charles A. Scott, MD, FAAP, a pediatrician at Medford Pediatric and Adolescent Medicine in Medford, N.J. The pediatrician must review the patient's history, take an initial evaluation and perform a follow-up lung check after the nebulizer treatment.

Scott recommends reporting a level-four established patient office visit if the pediatrician performs a detailed history, a detailed examination and medical decision-making of moderate complexity, at the minimum. Some pediatricians mistakenly believe that the exam is focused on the single problem of wheezing and therefore report a lower-level office visit (99213). But they are likely performing a detailed examination rather than an expanded problem-focused examination.

Apatient requiring an inhalation treatment is an urgent situation. Special service code 99058 (Office services provided on an emergency basis) appropriately describes an urgent situation or emergency, Tuck says. Therefore, you should report 99058 in addition to the office visit.