Pediatric Coding Alert

Question: A patient with a new diagnosis of asthma came to our practice to be educated on the correct use of a nebulizer and to receive a first treatment of albuterol. Can we bill for both the education, the treatment, and the spirometry measurements? And can we also bill for the medication, nebulizer mouthpiece, and tubing?

Pennsylvania Subscriber

Answer: The Correct Coding Initiative (CCI) views 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) as being bundled into 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). Simply put, if you have used the same device during the demonstration and the treatment, the demonstration is regarded as being a part of the treatment itself, and you can only bill the treatment.

However, under the right circumstances, you can separate the bundle and charge for both services. If, for example, the patient received the treatment, then the provider administering the treatment decided that the patient needed education on the correct way to use the nebulizer, which the patient received at a separate time, you could report 94664 with modifier 59 (Distinct procedural service) appended, as 94664 is the column 2 code in the CCI edit with 94640.

It is also possible to bill the teaching code if the teaching was on a metered dose inhaler (MDI) rather than the nebulizer. Many times, physicians will perform nebulizer treatments in their offices but order MDI's for at home use, and the patient or the patient's parents need training on that particular piece of equipment.

You cannot, however, bill for any pulmonary function testing you may perform before or after the treatment. Not only does the descriptor for 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) explicitly state that it includes pre- and post-bronchodilator administration, which is a nebulizer treatment, but both a parenthetical note after 94640 in the CPT^® manual and CCI edits state that you cannot report 94060, 94070 (Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents (eg, antigen[s], cold air, methacholine)), or 94400 (Breathing response to CO2 (CO2 response curve)) with 94640, which is the column 2 code in each CCI edit pair.

You can report the albuterol, as you would any therapeutic drug, vaccine, or inhaled medication, with codes such as J7609-J7611 (Albuterol, inhalation solution ... administered through DME ... 1 mg). However, disposable medical supplies such as those described by A7003 (Administration set, with small volume nonfiltered pneumatic nebulizer, disposable) are typically considered part of the practice expense component for a service such as 94640, which includes a nebulizer mouthpiece and tubing, and so are not billed separately.

As with all services and equipment, though, you should check with your payer to make sure you know what they will, and what they will not, cover.