Pediatric Coding Alert

Pediatricians are often confused about whether to code 94640 (nonpressurized inhalation treatment for acute airway obstruction) or CPT 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) for nebulizer encounters. The American Medical Association (AMA) and pediatric coding experts say to use code 94640 for nebulizing a patient. Code 94664 is for diagnostic, not therapeutic, purposesand also for teaching purposes.

Here is a typical scenario:

1. The case. A child comes in with an asthma attack. First, the nurse or doctor takes peak flow and pulse oximetry readings to determine the severity of the respiratory problem and the status of oxygenation. You would code 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) and 94760 (noninvasive ear or pulse oximetry for oxygen saturation; single determination), says A.D. Jacobson, MD, FAAP, a member of the American Academy of Pediatrics (AAP) Coding and Reimbursement Committee. Code 94010 is not for the hand-held peak flow meter that patients take home with them.

Note: Pulse oximetry has been bundled into the evaluation and management (E/M) services codes by Medicare, but this has not affected most private payers yet. Experts recommend you keep billing for pulse oximetry.

2. The confusion. Then, its time for the nebulizer. This is where practices differ on whether to use 94664 and 94665 (subsequent) or 94640. These appear to be very similar codes, but theyre not.

3. The coding. The correct code to use when you are nebulizing a patient who is having an asthma attack is 94640, according to the AMA. Not only for asthma, 94640 is reported for inhalation treatment for an acute airway obstruction, which could be, for example, croup (464.4) or asthma (493.9). Nonpressurized is included in the descriptor to differentiate this type of treatment from 94650 (intermittent positive pressure breathing [IPPB] treatment, air or oxygen, with or without nebulized medication; initial demonstration and/or evaluation). The bottom line is that when a child comes in and needs to be nebulized, you should use 94640. When you need to provide teaching on how to use the inhaler, you should use 94664.

94640 For Treatment and 94664 For Teaching

So 94664 is to be used for diagnostic purposes and also for teaching purposes. The same treatment that provides relief from the wheezingthe nebulizeralso produces sputum, which may be needed for laboratory cultures, for example. Code 94664 is not to be used when the nebulizing is done for therapeutic purposes, but when its done for diagnostic purposes. This may seem like a fine line, and often both goals are accomplished at the same time, but the AMA makes it clear that 94640 is the correct code to use when you are providing inhalation treatment for acute airway obstruction, whether you are using an aerosol or a nebulizer.

One of the reasons there has been so much confusion about these two codes may be the punctuation in the descriptor of 94664. The descriptor reads: aerosols or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation. It could be read to mean that the diagnostic purposes apply to sputum mobilization, bronchodilation, or sputum induction. But it only applies to sputum induction, according to Walter ODonohue, Jr., MD, FCCP, CPT advisor for the American College of Chest Physicians (ACCP), and chair of the CPT RVS Updating Committee (RUC) for the ACCP.

The main difference between 94640 and 94664 is the teaching component, says ODonohue. Why have two codes for administering a bronchodilator? he asks rhetorically. The difference is that one is for acute treatmentthe 94640and the other is for treatment and teaching. The key is the semicolon after the word purposes in the descriptor for 94664, says ODonohue. The emphasis is on the demonstration, the teaching, he says. I personally have never prescribed a metered-dose inhaler when I have not educated the patient on its use.

Coding For Teaching

The next question is whether you are going to be training the child and parent on the use of the nebulizer (and perhaps the peak flow meter) at home.

Jacobson notes that you cannot bill 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) with 94664 or 94665. If you spend 15 minutes or more doing training, my interpretation is that you cant bill 94664 as well, says Jacobson, who practices with Pediatric Associates in Phoenix, Ariz.

Jacobson is rightdemonstration in the descriptor of 94664 means education. You cannot bill 94664 with 97535. That is one of the reasons many pediatricians use 94664 when they provide educationthe code is inclusive of education, and the RVU is a bit higher than for 94640.

It should be noted that many, if not most, pediatricians are using 94664 incorrectly. It should also be noted that the fee ranges are very similar. The fee range for 94640 is $31 to $36, according to the HealthCare Consultants 1999 Physicians Fee & Coding Guide. For 94664, the fee range is $37 to $45, and for 94665 it is $32 to $38. However, you cannot bill for medications or supplies if you bill 94664; you can if you bill 94640. Also, you cannot bill for any education on the nebulizer if you bill 94664.

Richard Tuck, MD, FAAP, also notes that 94640 could include inspiratory or expiratory obstructions, and 94664, which is for bronchodilation, would just be for expiratory obstruction. Inspiratory would apply to croup or stridor; expiratory would apply to wheezing.

Coding Multiple Procedures

After you bill the nebulizer treatment with code 94640, you need to check the breathing (94010) and the oxygen saturation (94760) againso those codes are billed again. If the patient is improved, you can send him or her home. Your claim will have four or five (depending on whether you did teaching) lines: the office visit (probably a 99214 or a 99215), the nebulizer (94640), the spirometry (94010 x 2), and the pulse oximetry (94760 x 2). If you did teaching, also code 97535 (following Jacobsons method) or 94664-59 (following ODohonues method).

But what about the patient who does not improve after the first nebulizer treatment, and who stays in the office getting multiple treatments? You should code 94640 for each treatment given. You would also code the appropriate number of spirometry and pulse oximetry readings you must do.

If you are teaching and providing multiple nebulizer treatments on the same day, you should use 94640 for the treatments, and 94664 for the educational session, with a
-59 modifier on the 94664 to let the payer know that you did two separate procedures, says ODonohue.

The -76 modifier, which is recommended by the AMA for subsequent uses of 94640 on the same date, may not be necessary if you are dealing with commercial insurance companies, says Tuck. Its necessary only if insurance companies recognize and require it, he says. As long as they are reimbursing for the multiple treatments without the modifier, dont use it. Tuck uses 94640 multiple times and has no problem with reimbursement.

Sputum vs. Bronchodilation Specialty societies and the American Medical Association (AMA) still need to make the definitions of codes 94640 and 94664 more clear. One communication from the AMA states that the reference to diagnostic in codes 94664 and 94665 refers only to sputum, not to bronchodilation. But the AMAs explanation still makes it clear that if a child comes to your office wheezing, and you provide nebulizer treatment(s), the correct code is 94640, not 94664. The bronchodilation is inherent in codes 94664 and 94665 because with this use of the bronchodilator, the purpose of administering the bronchodilator is to provide the physiologic impetus to allow movement of the secretions (sputum) out of the lungs to help the patient breathe, when the patient has thick (tenacious) secretions, and is unable to remove them by coughing, the AMA says. In certain circumstances, the physician may order a single sputum collection or several specimen collections to be sent for laboratory culture and gram stain testing. Hence, the reference to diagnostic. The patient instruction is related to the use of the metered-dose inhaler or a small-volume nebulizer to therapeutically mobilize the secretions or to obtain a sputum specimen for diagnostic purposes (e.g., laboratory culture or gram stain). Richard Tuck, MD, FAAP, a member of the AAPs Coding and Reimbursement Committee, uses 94640 for nebulizer treatments. It would be much less common to do these treatments for diagnostic purposes in a primary-care pediatric practice than it is to do them for therapeutic purposes, he says. However, there are times when sputum must be obtained for laboratory analysis. And even bronchodilation can be done for diagnostic purposes. If you have a child who might have wheezing and you want to see if the nebulizer helps, that would be a diagnostic purpose, he says. Also sometimes a child is having studies, and you want to do pre- and post-treatment testing, and the nebulizer is part of that diagnostic procedure. Other than the pre- or post-test studies, however, you would not use bronchodilation as a diagnostic procedureby definition, it is therapeutic.

AMA to Clarify 94640/94664 There has been so much confusion about the codes for nebulizer encounters (94640 and 94664) that the American Medical Association (AMA) will be printing a clarification in CPT Assistant next month. The clarification will include the following information: Code 94640 is reported for an inhalation treatment for an acute airway obstruction, such as asthma or croup, and can represent an aerosol or nebulized administration of the appropriate medication, as prescribed by the physician. The term nonpressurized in the nomenclature of code 94640 differentiates the type of respiratory therapy treatment described by codes 94650 or 94651. Should repeated treatments be required on the same date, then code 94640 should be reported for each treatment performed. For example, a 6-year-old patient is seen in the office with diffuse wheezing and bronchospasm. A nebulized bronchodilator is administered using a metered-dose inhaler and chamber. The treatment is repeated after 30 minutes with good clinical response. In the above scenario, code 94640 should be reported twice (94640 and 94640-76). Code 94664 has several facets. First is the demonstration of a metered-dose inhaler or a small-volume nebulizer. Code 94664 can be reported when the bronchodilator is administered to assist in management of bronchospasm, effecting movement of tenacious sputum for therapeutic (i.e., sputum mobilization) or diagnostic (i.e., sputum induction for gram stain and culture) purposes. For example, a 7-year-old patient who has chronic asthma and thick secretions is seen in the office. The patient is placed on a metered-dose inhaler with a chamber, and the mother is instructed in the appropriate use of the device and medication. The patient is observed using the medication and evaluated for its appropriate use and response. Code 94665 describes the services as outlined above, but performed at a subsequent patient encounter. Code 97535 should not be reported for the patient instruction inherent in codes 94664 or 94665.