Pulmonology Coding Alert

J codes offer you the option of billing for albuterol - but not without a hitch

Your pulmonologists can come across a flurry of varying asthma and emphysema cases, but can you say you are still on top of your coding game?
 
Look at these three scenarios to see whether you can decipher the correct coding solutions for nebulizer treatments, respiratory drugs, and the appropriate E/M services.

Scenario 1: Acute Asthma Patient Receives Albuterol

A patient presents with acute exacerbation of asthma (493.02, Extrinsic asthma; with [acute] exacerbation). The nurse, who's working under your pulmonologist's supervision, administers albuterol using a metered-dose inhaler.

Answer: You should 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]) for the nebulizer treatment, says Michele Wendling, billing manager with Midwest Medical Services in Troy, Ohio. 

If you want to bill for the albuterol, you should list the appropriate J code, such as J7613 (Albuterol, inhalation solution, administered through DME, unit dose, 1 mg), Wendling says.

Warning: If you report code J7613 in addition to 94640 to your Medicare carriers, don't expect to get paid, Wendling says. Medicare considers 94640's reimbursement to cover the drug charge. Private insurers may pay separately for the drug, Wendling adds.

Heads-up: To get paid under this circumstance, you'd have to ensure the visit meets "incident-to" billing requirements, because the nurse, not the physician, provided the nebulizer treatment.

This means that the supervising pulmonologist must be physically present in the same office suite and immediately available to assist if necessary.

Scenario 2: Inhalation Treatment, Instruction for Emphysema Patient

An established patient with emphysema (492.8, Other emphysema, lung) comes into your pulmonology practice complaining of shortness of breath (786.05).

The pulmonologist provides inhalation treatment and then trains the patient on how to use the nebulizer at home. The pulmonologist also provides an expanded problem-focused examination and medical decision-making of low complexity.

Answer: In this case, you should report 94640 to cover the comprehensive service the physician provided. Report 94640 over 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered- dose inhaler or IPPB device) since the primary intent of the pulmonologist was to treat the obstruction, Wendling says.

But if you bill 94664 along with 94640 on the same day to Medicare, make sure you justify that the pulmonologist provided the 94664 service distinctly separate from the treatment, coding experts say.

Extra: In this case, attach modifier -59 (Distinct procedural service) to 94664 to notify the payer that the pulmonologist performed 94664 distinctly separate from 94640, Wendling says.

The documentation should include details on the medical necessity for providing this service. An example of the documentation is that the pulmonologist determined the patient's plan of care should include inhalation therapy, or the patient is new to this therapy and does not know the administration techniques involved in the procedure. 

The note should clearly identify that the pulmonologist demonstrated the inhaler to the patient separate from the administration for treatment. Otherwise, the insurer may think you are trying to bill twice for one service, experts say. 

Exception: On the other hand, a private carrier may allow you to assign 94640 and 94664 without a modifier if the carrier allows practices to report both on the same day and doesn't follow the National Correct Coding Initiative (NCCI) guidelines.

Because the physician also performed an office visit, you should report 99213 (Office or other outpatient visit for the E/M of an established patient).

Remember: Codes 94640 and 94664 do not include E/M services. And 94640 and 94664 have "XXX" global days, which means that the global package concept does not apply. Therefore, you do not need to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, coding experts say.

Tip: It is always helpful to link separate diagnosis codes to the E/M and the nebulizer treatment. For instance, you could link 786.05 (Shortness of breath) to 99213, and link the emphysema code (492.8) to 94640.

Scenario 3: Nurse Only Gives Nebulizer Training

Your nurse provides nebulizer training to an established patient who has acute bronchitis (466.0). The primary reason for the visit was the training. The nurse performs no other procedures or services.

Answer: In this situation, you should report only 94664, but not a nurse visit code (99211). That's because the patient presented to the office for training on how to use the nebulizer and did not receive any further evaluation or treatment.

Note: Questions and answers reviewed by Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.