Pediatric Coding Alert

Question: I just received a denial after reporting 99213 with 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or ippb device). Should I bill the 99213 with a 25 modifier or should I bill 94664 with a 59 modifier? The diagnoses were 486 (Pneumonia organism, unspecified) and 786.07 (Wheezing).

Georgia Subscriber

Answer: No CCI edit exists that would preclude you from reporting 99213 with 94664. However, many insurers do require modifiers on these claims anyway. Most payers will report that they want you to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M visit code (99213-25).

Other payers, however, may prefer that you append modifier 59 (Distinct procedural service) to 94664. This is typically required if a therapeutic aerosol is given at the time of the visit (94640), after which instruction on a home aerosol device is provided. This would be coded with 99213-25, 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes), 94664-59.