Pediatric Coding Alert

Question: We have been billing 94640 with 94664, using modifier 59 on the nebulizer demonstration, and we have been getting denials. What are we doing wrong?

Florida Subscriber

Answer: When you bill 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) along with 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device), the demonstration is considered bundled into the therapeutic procedure.

However, per National Correct Coding Initiative (NCCI, or CCI) edits, the edit pair has a modifier indicator of 1. In other words, when 94640 is the column 1 code, 94664 can be unbundled with the appropriate modifier. While the one you have chosen — modifier 59 (Distinct procedural service) — is appropriate, it is possible that your payer may recognize one of the HCPCS X{EPSU} modifiers that CMS introduced in 2015 to substitute for modifier 59 when appropriate.

If this is the case, then you could use modifier XU (Unusual non-overlapping service) on the 94664. You can use this modifier “when a diagnostic procedure occurs subsequent to a completed therapeutic procedure and when the diagnostic procedure is not a commonly accepted or necessary follow-up to the therapeutic procedure,” according to Medicare Administrative Contractor (MAC) Noridian.

You will need to check with your payer to see if they will accept the XU modifier, however.