Pediatric Coding Alert

Before you bill for your next nebulizer treatment dose, you'd better check payers' policies -- or risk nonpayment.

When discussing coding for asthmatic treatment sessions, you're bound to hear about new Q codes floating around for albuterol. Should you use them? Cut through the confusion with these fast facts.

For some payers, you might be able to forget the J codes you just learned two short years ago. CMS is changing the HCPCS level-II codes associated with albuterol and levalbuterol again. Effective July 1, 2007, Medicare Part B carriers will no longer pay for:

New way: When a practice purchases and provides inhalation solution for a nebulizer treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device) and for pre/post spirometry (94060, Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) due to asthma exacerbation (478.0), carriers instead require:

Time-saver: You can overlook the Q codes' lengthy descriptors and zoom in on one factor: the inhalation solution's form. The only difference between the new inhalation solution Q codes is that Q4093 is for the concentrated form and Q4094 is for unit dose, says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare in Zanesville, Ohio.

Although the new Q codes come from Medicare, other insurers may adopt them. For instance, Blue Cross and Blue Shield of Minnesota and Blue Plus are implementing the albuterol supply code changes, effective July 1, 2007.

Not all insurers may be so swift to replace J7611-J7614 with Q4093-Q4094. Non-Medicare Part B insurers may still accept the current J codes, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

Why: The AMA has not deleted the J codes, Pohlig points out. "Therefore, J7611-J7614 are still fair game for non-Medicare Part B payers."

Until the J codes are deleted from the HCPCS manual, you'll have to use the payer-preferred supply code. Expect to report albuterol/levalbuterol supply one of three ways:

Method 1: Private payers that never utilize the HCPCS codes, and only utilize standard CPT codes, will require 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]).

Method 2: For non-Medicare Part B insurers that continue to accept the J codes, continue to use J7611-J7614.

Method 3: Use Q codes for plans such as BCBS of Minnesota and Blue Plus that implement the albuterol HCPCS level-II code switch immediately. When looking at the new Q codes equate:

• Q4093 with J7611 or J7612

• Q4094 with J7613 or J7614.

How can you find out if your insurer wants the Q codes? Try these real-world tips from Rhonda Buckholtz, CPC, administrator at Wolf Creek Medical Associates in Grove City, Pa.:

* Use your private payers' online tools and resources to check the new codes' availability, payment and policies.

* Carefully read all of your Medicaid remits. Medicaid is usually last to make any code changes, which usually appear as a small line item on an RA

* Sign up for list serv notices to stay informed of any changes.

Do not use a HCPCS level-II code to bill for a drug, such as albuterol, when your practice receives it for free. For instance, if a pharmaceutical company provides free samples for your practice to use for inhalation therapy, you should not code for the supply.

When coding for inhalation solution, make sure you capture the encounter's related procedure(s) and services. Possibilities include:

* an office visit (99201-99215, Office or other outpatient visit ...) for the history, examination and medical decision-making of a patient with exacerbated asthma (478.0) that led to the treatment. Although CPT does not require modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service) on claims involving an E/M service and medicine code, insurers may necessitate the modifier on the associated E/M code.

* aerosol administration (94640)

* instruction in the use of a home nebulizer or handheld inhaler/spacing as needed (94664, Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device). "The nurse or medical technician who provided the hand-held nebulizer instruction should separately document the instruction, and the supervising physician should countersign the note," Tuck says.