Primary Care Coding Alert

Question: Should we use 94664 when a nurse provides education/demonstration/monitoring to the patient on a nebulizer-type device? We-ve never billed it before, but the Medicare fee schedule shows it pays more than the nebulizer code. Can I bill for this?

Idaho Subscriber

Answer: You are correct that you may be able to report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) if a nurse or other provider shows a patient how to use a nebulizer-type device, such as an inhaler; teaches the patient proper usage including hold and dosing; or observes the patient using the device. The physician or nonphysician provider (NPP) who orders the nebulizer education should indicate the medical necessity for the service, such as incorrect handhold, new prescription, etc.

Beware: Although the inhaler evaluation code (0.41 total relative value units [RVUs] or approximately $15) pays more than the inhalation treatment code (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; 0.37 RVUs or $13),
the Correct Coding Initiative (CCI) bundles 94664 (the higher-paid code) into 94640 (the lower-paid code). The 2009 Medicare Physician Fee Schedule assigns 0.02 more practice expense RVUs and 0.02 more malpractice RVUs to 94664 than to 94640. The increased values represent 94664's additional clinical staff time and liability insurance expense.

CCI's 94664-94640 edit allows a modifier to override the bundle when circumstances make separately reporting the education appropriate. For Medicare and payers that follow the edits, if the education occurs while the patient is receiving the inhalation treatment, do not separately bill the education. If, however, the FP provides the inhalation treatment, and recommends the patient receive education, and the nurse subsequently performs the training at a separate session, you may report 94664 with modifier 59 (Distinct procedural service).

When the FP or NPP performs and documents a medically necessary E/M service prior to providing the inhalation treatment or education, some payers may require you to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the office visit code (99201-99215).