Primary Care Coding Alert
Provide Purpose for Clear Breathing Treatment Documentation
Question: I have been asking my providers for pre- and post-treatment descriptions when documenting 94640, but they don’t believe they need to provide them. Are they right? What guidelines should I use to make sure I have the right documentation? North Carolina Subscriber Answer: According to the National Correct Coding Initiative (NCCI, or CCI) Policy Manual for Medicare Services, if 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) “is used for treatment of acute airway obstruction, spirometry measurements before and/or after the treatment(s) shall not be reported separately” (Source: Chapter 11, section J, 7-9). In other words, pre- and post-treatment spirometry measurements such as 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) should never be reported together with 94640 because Medicare believes the measurements are already bundled into the treatment service. Or, as the CCI manual goes on to say, “it is a misuse of CPT® code 94060 to report it in addition to CPT® code 94640.” However, the wording of the policy for 94640, and the fact that CCI has assigned a modifier indicator of 1 when 94060 is bundled into 94640 (when 94060 is the column one code and 94640 is the column two code of the edit pair), means that you can unbundle the pair, presumably when 94640 is being used for diagnostic purposes. If that is the case, you will need to make sure you append modifier 59 (Distinct procedural service) to the 94640 and ask your providers to clearly document that they performed 94640 as a diagnostic test and not as a therapeutic treatment. (To view the full NCCI policy manual, go to www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html and download the zip file “NCCI Policy Manual for Medicare Services – Effective January 1, 2019”).
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