Pediatric Coding Alert

When coding for nebulizer treatments, pediatricians may choose either CPT 94640 (nonpressurized inhalation treatment for acute airway obstruction) or 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation).

If treating a child with a nebulizer for the purpose of improving breathing, use the simple therapy code 94640. A typical 94640 pediatric scenario might involve a 1-year-old who presents with acute wheezing, is treated with an aerosol, improves and is sent home on oral albuterol.

For teaching a child and/or parent how to use a nebulizer during the same encounter in which you provide a nebulizer treatment, use 94664. This common situation arises, for example, when a baby or child first develops wheezing whether from bronchitis, asthma or some other problem. After giving a treatment in the office and determining that it has improved breathing, the pediatrician prescribes home nebulizer treatments. The pediatrician then teaches the child and/or parent how to use the nebulizer.

In another example, a child with recurrent wheezing is diagnosed with asthma and begins outpatient treatment with an albuterol inhaler. Again, 94664 is appropriately reported for demonstrating to the patient proper use of the inhaler.

Note: The descriptor for 94664 does not specifically refer to teaching or training, but does mention demonstration.

If a nurse, rather than a physician, provides the training, report 97535 (self care/home management training [e.g., activities of daily living [ADL] and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment] direct one-on-one contact by provider, each 15 minutes). Do not bill 94664 and 97535 together.

Bill Modifier -59 With 94640 and 94664 Appropriately

You can bill 94640 and 94664 together. You may have to provide treatment and training on the same day, for instance, especially if the child has never used a nebulizer before. The national Correct Coding Initiative bundles these two codes, however, and therefore you must append modifier -59 (distinct procedural service) to 94640.

Both procedures [94664 and 94640] are usually billed with and given during an E/M service that involves an asthma or respiratory problem, explains Joel F. Bradley, MD, FAAP, editor of Coding for Pediatrics and a member of the AAP coding and reimbursement committee. If a patient undergoes a treatment and is also instructed in the use of the nebulizer or the inhaler, 94664 is billed. If further nebulization is required after the teaching nebulizer, code 94640 as well, he recommends.

Bill Units and 97535

For multiple nebulizations, some coders believe its better to report 94640 in units and access the teaching code (97535) instead of 94664. For instance, if a child requires three nebulizations, code 94640 x 2 and 97535 for teaching. Do not code 94664 in addition.

Code 94664 can only be used once per lifetime, according to Walter J. ODonohue Jr., MD, FCCP, FACP, representative to the AMA CPT Advisory Committee for the American College of Chest Physicians. In other words, you must use the lower-paying companion code, 94665 (aerosol or vapor inhalations subsequent) for any repeat training given to the parent or child. Code 94640, however, can be used many times a day.

E/M Service Also Applies

The pediatrician may also bill an E/M service when a child presents for a nebulizer treatment. In fact, the child is coming for a medical evaluation; after taking a history, examining the child and making medical decisions, the physician determines that nebulization is the correct next step. This is typically a level-three or -four service.

For example, a mother complains that her 2-year-old seems to have a cold, isnt eating well and is having trouble breathing. The pediatrician immediately finds retractions and wheezing and orders a nebulizer treatment which the nurse initiates and the mother performs. The physician returns 10 minutes later to evaluate the child, decides that another nebulizer treatment is necessary, and again returns in 10 minutes for an evaluation. The patient improves and is sent home after the nurse provides training on how to use the nebulizer.

This service includes extensive discussion regarding the diagnosis, the initiation of a long-term treatment plan and counseling on medication. Based on time alone, the visit may qualify as a 99214. The entire service should be coded as follows:

99214
94640-59
94640-59-76
94664

Note: Modifier -76 (repeat procedure by same physician) indicates that 94640 was repeated.

Alternatively, if a nurse provides the training, bill 97535 instead of 94664.

Claim Prolonged Services Instead of 94664

Training can be complicated the pediatrician must instruct the parent on how to use the nebulizer, the correct dosage, when to do a peak flow and when to add medication and 94664 may not adequately reimburse for the time, as much as 30 minutes, required to perform the service. This time, in addition to time spent on evaluations after the treatments are performed, could total 45 minutes or more.

For this reason, some coders prefer to use prolonged services codes instead of 94664. Use add-on code +99354 (prolonged physician service in the office or other outpatient setting ) in addition to the appropriate established-patient E/M code for the 30 minutes spent on training.

Using the above example, but reporting prolonged services instead of 94664, the service is coded as follows:

99213
+99354
94640
94640-76

Neither 94664 nor 97535 should be claimed in this case.

Note: Some payers require modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) be appended to office visits listed with other procedures.