Primary Care Coding Alert

Question: Which CPT code should we report when an established patient with emphysema presents complaining of shortness of breath? The physician provides inhalation treatment, trains the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision-making of low complexity.Answer: You'll need more than one CPT code for this encounter. Report 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]) to cover the comprehensive service the physician provided.Because the physician also performed an office visit, report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...), based on your documentation of an expanded problem-focused exam with low-complexity decision-making. You might need to append modifier 25 to 99213 to indicate that the E/M service was significant [...]