Pediatric Coding Alert

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 [...]