Primary Care Coding Alert

Question: Our physician provided two inhalation treatments to the same patient on the same day. How should we document this, and can we document the use of nebulizer supplies such as A7003 (Administration set, with small volume nonfiltered pneumatic nebulizer, disposable) along with the procedure?

West Virginia Subscriber

Answer: You would begin by using 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) to document the treatment, assuming that it was not a continuous treatment that lasted for an hour or more. If it did, then you would report 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour) with an add-on of 94645 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour) to code for an additional hour, if necessary.

Because the physician provided two separate treatments, you would report 94640 twice. As the treatments occurred on the same day, you would then append modifier 76 (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional) to the second occurrence to show that they were two separate procedures. This is consistent with a parenthetical instruction following code 94640 in CPT^®, which states “For more than 1 inhalation treatment performed on the same date, append modifier 76.”

It is also consistent with the Correct Coding Institute (CCI) guidelines, which allow you to report inhaled medication, such as J7610 (Albuterol, inhalation solution, compounded product, administered through DME, concentrated form, 1 mg), separately, just as you would report the code for a therapeutic drug or vaccine in addition to the code for its administration.

You will need to check with the payer in question about separately reporting other supplies with a code such as A7003. Typically, disposable medical supplies are considered part of the practice expense component of the payment for the service itself and not separately reportable. For instance, the practice expenses included in the relative value assigned to code 94640 include a nebulizer mouthpiece with tubing, which may duplicate what is included in the administration set described by code A7003.

In addition, if the physician performed and documented the work associated with an evaluation and management (E/M) service during the encounter, you would also code an office visit using an appropriate E/M code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient …), with 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) appended to indicate the patient has received a significant and separate E/M service.

Note: Only code for a separate E/M if you have rock-solid proof that the physician performed a significant, separately identifiable E/M before administering the treatment. If you have any doubt about whether a separate E/M occurred, check with the physician before filing the claim.

Coding alert: Never report 94640 with 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration), 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]). These are all pulmonary function tests, and even if you have taken spirometry measurements before and after the treatment, CCI does not permit you to report the procedures separately, unless circumstances support separate reporting through application of an appropriate modifier to 94640, which is the column 2 code in each CCI edit pair. This general prohibition on reporting 94640 in conjunction with 94060, 94070, or 94400 is supported by a parenthetical instruction to the same effect found after code 94640 in CPT^®.

Similarly, CCI does not allow you to report 94640 with 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) if the same device is used in performance of the treatment, as the demonstration is included in the service. You can report a demonstration of the generator on the same day if it occurred at a different time from the treatment. In that case, append modifier 59 (Distinct Procedural Service) to code 94664, since it is the Column 2 code in the CCI edit with 94640.