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 [...]