Family practice coders struggle with how to report several nebulizer encounter codes and say unclear verbiage is the primary cause of the confusion. Three codes in particular puzzle coders, who note that fuzzy definitions often lead to miscoding and may result in lower reimbursements.
The chief offenders are:
" 94640 (nonpressurized inhalation treatment for acute airway obstruction),
" 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation or sputum induction for diagnostic purposes; initial demonstration and/or evaluation), and
" 94665 (& subsequent).
Despite the confusion over CPT s language, there are a few twists within these code definitions that distinguish them, explains Carol Pohlig, BSN, RN, CPC, a reimburse-ment analyst for the office of clinical documentation in the department of medicine at the University of Pennsylvania in Philadelphia. There are specific circumstances when one, but not the other, should be assigned.
Assign 94640 for Treatment of Acute Episodes
When a patient has trouble breathing and receives a nebulizer treatment in the office, coders would assign 94640. This code is exclusively used for treatment of acute episodes, Pohlig says.
For instance, a 36-year-old woman with a history of asthma and allergies suffers an acute flare-up. She comes into the office and is nebulized. Coders should report 94640 with a diagnosis code of 493.00 (extrinsic asthma, without mention of status asthmaticus). The office visit is also reported using the appropriate E/M code and attaching modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
The treatment may need to be repeated during the visit, and each treatment should be reported with 94640. Modifier -76 (repeat procedure by same physician) should be appended to each subsequent code.
Although asthma is a common condition requiring the treatment as reflected in 94640, it is not the only condition that prompts nebulization. Treatment may be given for any acute airway obstruction, she notes. The term obstruction in the definition doesn t mean there is a foreign body lodged in the airway. It refers to any condition that prevents air from flowing in and out of the lungs freely. For instance, the bronchial airway may be swollen because of infection and that constitutes an obstruction. Croup (464.4), for example, may require a nebulizer treatment.
The reference to nonpressurized in the definition for 94640 is important as well, Pohlig explains, because it differentiates this treatment from similar therapies in the pulmonary section of CPT (e.g., 94650, intermittent positive pressure breathing [IPPB] treatment, air or oxygen, with or without nebulized medication; initial demonstration and/or evaluation, would not be used in treatment scenarios described above).
In addition to the service code, family practices may report medication and supply codes.
Assign 94664 for Diagnostic Tests and for Teaching
Code 94664 is designated for very different uses, Pohlig explains. The key words in the definition are evaluation, which refers to a diagnostic test, and demonstration, which indicates patient education on how to use a metered-dose inhaler [MDI] or nebulizer.
Coding experts note that many family practices assign 94664 improperly reporting it when treating patients for an acute attack. One reason for the error is that the same medications and devices are used for 94640 and 94664, and the diagnostic service therefore produces therapeutic results, as well (i.e., the breathing difficulty is relieved). Family physicians and coders must recognize, however, that the intent behind the two codes is different, says Pohlig.
Another reason for the confusion is the term nonpressurized in the definition of code 94640. Physicians and coders may believe that since an MDI is a pressurized canister, it cannot be used with 94640. However, they should understand that the term nonpressurized is an attempt to distinguish this therapy from positive airway pressure. It is not intended to describe the delivery mechanism inherent in an MDI.
When 94664 is used for diagnostic purposes, the patient receives nebulized medication to help produce a sputum specimen. For instance, a 58-year-old man may be seen in the office because he has increased difficulty breathing. He is not experiencing an acute problem like an asthma attack, but the family physician needs to determine what is causing the condition. The physician will ask the patient to inhale a medication to help bring up sputum, which will then be evaluated. It might be tested for bacteria, for instance, or evaluated for viscosity, color or smell.
Likewise, says Wendy Walker, CPC, coding and chart auditor for Central Penn Medical Group in East Petersburg, Pa., the physician or staff member may need to demonstrate how a therapeutic inhaler should be used once a diagnosis has been determined. She notes, for instance, that a practitioner might spend time with the patient to ensure he or she is able to use the device properly for maximum effectiveness.
Coding Subsequent Demonstrations
Walker adds that 94665 should be assigned for subsequent demonstrations or training in the use of the inhaler, at a later date. Patients, may have trouble with the inhaler or may not be using it effectively.
We will often call a patient a week after an inhaler has been prescribed. If necessary, we ask them to return to the office to repeat the education, adds Pohlig. She emphasizes that the initial demonstration code, 94664, can be used only once during a patient s lifetime or his or her participation with any given insurer. Any other education should be coded with 94665.
Note: Some coders question whether 94665 may be assigned when a nurse provides the subsequent instruction, because there was no physician participation. Pohlig notes that it is correct to report 94665, because it is a technical-component-only code and carries no physician work relative value units (RVUs).
Medication and supplies may not be billed in addition to 94664 or 94665.
On occasion a patient may need a treatment, following training on an inhaler. For instance, instructions are given and the patient uses the inhaler properly and does not experience full relief. After 30 minutes, another treatment is given. Coding experts recommend that both 94664 and 94640 be reported for the encounter. Alternatively, the physician may treat an acute attack and then provide training on an MDI. Both 94640 and 94664 may be reported in this instance as well. In cases like this, coders should attach modifier -59 (distinct procedural service) to the second code.
