Pediatric Coding Alert

Question: We are starting to do asthma education with our asthma follow-up patients. Do I need a modifier on 99403 when billing with an E/M code such as 99214?

Answer: Depending on what’s involved in the education that you’re providing, 99403 (Preventive medicine counseling and/or risk factor reduction intervention [s] provided to an individual [separate procedure]; approximately 45 minutes) is probably not your best bet.

CPT^® says that 99403 is for “persons without a specific illness for which counseling might otherwise be used as part of treatment.” Since your patients have asthma, you’re better off reporting 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) if you’re doing education on how to use the nebulizer or aerosol puffer.

You may need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to reflect that it was significant and separately identifiable from the evaluation done as part of 94664. Some payers require you to add modifier 25 while others would not require it. It is always important to check with your top payers for their specific regulations.

If a physician or other qualified healthcare professional performs asthma education or counseling, then using the office visit codes based on time as a key factor could be the best way to bill for this type of service. Billing based on time means the provider has to document the total amount of time in the visit and that greater than 50 percent of that time was spent in counseling on the asthma education. For example, if you spent a total of 19 minutes on the visit, 13 of which was spent counseling the patient about her asthma, you could report 99213.