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Pediatric Coding Alert

Success Story:

You Can Get Paid for Same-Session Teaching, Nebulization

Published on Thu Apr 14, 2005

Action: Designate 94664 as a distinct procedural service

To obtain inhaler demonstration reimbursement, pediatric coders are adopting modifier -59 as the latest AAP-approved tactic.

Unlock Instruction Pay With CPT 94664 -59

Several payers will only reimburse for the first 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]) but not the teaching (94664, Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device), writes Anika Potts, office administrator at Kids First Pediatric Group in Stockbridge, Ga. "Do you have any suggestions on how to get the demo paid?"

Try this: You could append modifier -59 (Distinct procedural service) to 94664, says Christina T. Todd, CCS-P, director of medical review & compliance at EHS
Inc. in Hunt Valley, Md. "We've had better success getting paid for the teaching since we started reporting 94664-59."

Identify Demo as Distinct

When you report same-session nebulizer treatment and training, you may use modifier -59 to designate 94664 as a distinct procedural service from 94640. "Modifier -59 indicates that you perform two distinct, separate procedures with individual CPT codes," says Richard Tuck, MD, FAAP, a member of the American Academy of Pediatrics (AAP) national committee on coding and nomenclature (COCN).

Caution: "Not all payers require modifier -59 on the nebulizer demonstration code," Tuck says. But you might have to use the modifier if an insurer includes the training in the treatment.

Why: The National Correct Coding Initiative (NCCI) considers 94664 a component of 94640. Therefore, private payers may adopt the CMS edit and include the demonstra-tion in the training.

Use -59 for Different Procedure

You can use modifier -59 to unbundle the demonstration (94664) from the treatment (94640). "Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day," states CPT Appendix A - Modifiers.

Modifier -59 may represent one of the following relationships between the two procedures/services:
 

  • different session or patient encounter
     
  • different procedure or surgery
     
  • different site or organ system
     
  • separate incision/excision
     
  • separate lesion
     
  • separate injury.

    Example: An established patient presents in respiratory distress. You evaluate the child and administer a nebulizer treatment using a unit dose of Albuterol.

    After the child recovers, you prescribe a new inhaler. A nurse demonstrates proper inhaler technique, has the child practice using the inhaler and corrects the patient's misuse. 

    Solution: You could code the encounter as:

    CPT codes: 

  • 99212-99215 Modifier -25 - significant, separately identifiable office visit
     
  • 94640 - nebulizer treatment
     
  • 94664 Modifier 59 - distinct procedural training
     
  • J7613 - unit dose of Albuterol.

    ICD-9 code:
     
  • 493.02 - asthma with exacerbation.
     
    E/M: You would report 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient) appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). "Modifier -25 identifies the asthma evaluation as significant and separately identifiable from the nebulizer treatment (94640)," Tuck says.
     
    Other services/procedures: Report 94640 for the inhalation treatment and 94664 for the nurse's inhaler demonstration and evaluation. Append modifier -59 to 94664 because it is the bundled code.
     
    Supply: Use the new HCPCS code for a unit dose of Albuterol: J7613 (Albuterol, inhalation solution, administered through DME, unit dose, 1 mg).
     
    Diagnosis: For the ICD-9 code, you would assign 493.02 (Extrinsic asthma; with [acute] exacerbation). The fifth-digit subclassification of "2" indicates the patient was in respiratory distress.

    Check if Insurer Permits -59

    Before you report 94664-59 to an insurance company, make sure it accepts modifier -59. "Georgia Medicaid does not recognize this modifier. Do not use this modifier on Medicaid/PeachCare claims as a system edit error will allow payment incorrectly," warns the Georgia AAP in its coding and compliance tip sheet.

    Code Demo Regardless of Payment

    Regional differences also come into play with teaching reimbursement. "We have no insurers that pay on the demo code," says Richard Lander, MD, FAAP, a pediatrician at Essex-Morris Pediatric Group in Livingston, N.J.

    Best practice: Lander still bills the training code every time he performs the service. "Some day a company may pay for the procedure," he says. Plus, CPT guidelines require you to code everything you do.

    On the other hand, West Coast practices may have an easier time obtaining 94664 payment even without a modifier. "We have no trouble getting paid for nurse training at a nebulizer treatment encounter," says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif.

    Write Teaching, Treatment Paragraphs

    If insurers are bundling 94664 into 94640, separate documentation could help you overturn denials. "The pediatrician should clearly document the demo and treatment as separate procedures," Jackson says.

    How to: Use one paragraph for the treatment and another paragraph for the training. This visually shows an insurer that each procedure is different. Often, a nurse performs the demonstration as part of the pediatrician's services.

    Treatment: A child comes into the office complaining of respiratory distress. The pediatrician administers a nebulizer treatment.

    Training: A nurse asks the child to demonstrate how he uses the device. The child is incorrectly using the nebulizer. So the nurse demonstrates proper inhaler technique and points out the patient's problems.

    Don't forget: The nurse dates and signs her entry, which the pediatrician countersigns. The signatures show the training as incident-to the physician.

    Query Denial Reason

    Call the insurance company and ask whether they cover the training. "If the representative says no, ask him why," says Chip Hart, marketer for the Winooski, Va.-based Physician's Computer Company.

    Inform the insurer that you are billing based on CPT guidelines that allow coding each procedure. If the representative responds that he is too, you may be able to convince him to re-examine covering 94664, Hart says.

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