Primary Care Coding Alert

Inhaler demo could pay you $16 -- if you know how to navigate the rules.

When the nurse or medical assistant spends time helping a patient with an inhaler demo or evaluation, you have three areas to keep in mind before coding: the type of device used, documentation requirements, and qualifying modifiers. Follow these four tips from our experts to understand why some payers might deny payment for the service -- and what you can do to win deserved dollars.

1. Categorize the Diskus Correctly

Many physician offices use the Advair Diskus for their patients, which is an aerosol generator. "An aerosol generator is a device that produces airborne suspensions of small particles for inhalation therapy," explains Peter Koukounas, owner of Hippocratic Solutions medical billing service in Fairfield, N.J. If the nurse or medical assistant taught someone to use an Advair Diskus -- or any other diskus -- you should report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

Example: The physician starts a patient with asthma (493.00, Extrinsic asthma; unspecified or 493.20, Chronic obstructive asthma; unspecified) on Advair. A nurse then teaches the patient how to use the Diskus. According to CPT guidelines, you should report 99201-99215 for the office visit (depending on whether you're treating a new or established patient). Then report 94664, but don't append a modifier, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

Here's why: CMS transmittal R954CP indicates that modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) applies only to E/M services performed with procedures that have a global fee period. Code 94664 does not have a global fee period, which is why you don't automatically include modifier 25.

Exception: Despite what CMS guidelines might state, many payers will only reimburse for the service if you append modifier 25 to the visit code. Check your major insurers' policies to learn their requirements.

2. Include Treatment in Teaching Session

The physician might administer a medication dose during the teaching session. If so, remember that both services (treatment + teaching) are bundled into 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]). Because of this, you'll only report 94640 since the physician performed the administration as part of the demonstration/evaluation.

3. Remember Modifier 59 for Extra Education

Consider this scenario: An asthmatic patient is wheezing and having difficulty breathing during an outpatient visit. She requires one or more bronchodilator treatments for intervention: 493.01 (Extrinsic asthma; with status asthmaticus), 493.02 (Extrinsic asthma; with [acute] exacerbation), 493.21 (Chronic obstructive asthma; with status asthmaticus), or 493.22 (Chronic obstructive asthma; with [acute] exacerbation). During questioning, your physician discovers that the patient didn't use her MDI device or nebulizer properly prior to her visit. After he treats the patient, he provides her with additional education about how to use the devices.

Code it: First, report 94640. If your physician offers multiple treatments, report 94640 the appropriate number of times and append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional). Include the appropriate E/M code without a modifier, unless the payer requires modifier 25 with the E/M. Next, report 94664 with modifier 59 (Distinct procedural service), as the patient required additional instruction for his daily maintenance medication. This is different from the medication provided for immediate intervention (94640).

In short: If the patient required separate education after receiving an inhalation treatment on the same day, you would bill both services (treatment + education), appending modifier 59 to 94664.

Logic: The Correct Coding Initiative (CCI) edit on 94640 and 94664 has a "1" in the modifier column, signaling that you can override the edit with the proper modifier. So Medicare and payers that follow CCI edits will require modifier 59 on the component code (94664) to indicate that the teaching is a distinct procedural service from the inhalation treatment.

4. Prove Medical Necessity

Reporting 94664 can garner almost $16 for your physician, based on the national Medicare non-facility rate payment schedule. Do your part in achieving reimbursement by encouraging physicians to document medical necessity for 94664.

Example: Ask your physicians to document in the plan or treatment portion of the written record that the patient requires a teaching session on the use of his MDI, diskus, nebulizer, etc. In addition, don't forget to document why the session is necessary. "Remember, if you don't document what occurred, the payers will consider it didn't happen," Plummer reminds.