Pediatric Coding Alert

Question: We recently reported nebulizer treatment (94640) with an E/M visit and the E/M service got denied due to CCI edits. Why did this happen, and how can I fix it going forward?

Answer: Effective Jan. 1, CCI version 20.0 began bundling all of the problem-oriented office visit codes (99201-99215) into the nebulizer code 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [eg, with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device]). 

This means that your payer will deny the E/M service for these claims. There is a way around it, however. The edit has a modifier of “1,” which means you can report the two services together if you can prove that the E/M visit was medically necessary and separately identifiable from the nebulizer treatment. If that’s the case, you’ll append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M service.

The same is true of codes 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation), 94620 (Pulmonary stress testing; simple [eg, 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry]) and 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration), all of which have E/M codes included in them effective Jan. 1, but can be billed with a 25 modifier on the E/M code if your documentation demonstrates the medically necessary, separate E/M service.