Pulmonology Coding Alert

An acute asthmatic (ICD-9 493.00 - 493.91 ) patient experiencing a bronchospasm presents to the pulmonologists office. The pulmonologist treats the patient with a non-pressurized albuterol nebulizer, after which the patient begins to breathe normally. The coder erroneously assigns 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) to the claim, noting that the codes descriptor cites aerosol inhalations for bronchodilation. But this is not the most accurate code for this treatment.

Unfortunately, pulmonology practices still make this common error. Of the 23 practices we polled, nearly one-third of them were coding therapeutic aerosol inhalation treatments as 94664. According to Carol Pohlig, BSN, RN, CPC, reimbursement analyst at the Hospital of the University of Pennsylvanias department of medicine in Philadelphia, 94664 should be reserved specifically for diagnostic treatments and/or training purposes. The correct code for billing therapeutic aerosol inhalations is 94640 (nonpressurized inhalation treatment for acute airway obstruction). In addition, says Pohlig, this scenario also permits the billing of albuterol using J7619-J7625.

Most Medicare policies limit the use of 94640 to treatment for acute airway obstruction only and imposes other limitations on 94664. For example, Georgias Part B Medicare policy states, Codes 94664 and 94665 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; subsequent) are billed when inhalations are done to mobilize sputum, for bronchodilation or to induct sputum for diagnostic purposes. Code 94664 only once per episode of illness. Use 94665 for additional inhalation treatments.

Billing Nebulizer Treatments With Other Codes

We have had problems billing 94640 with methacholine challenges (94070, prolonged postexposure evaluation of bronschospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics), says Marci Winter, office manager at Pulmonary Consultants, an eight-pulmonologist practice in Tacoma, Wash. If the patient has a reaction during a methacholine challenge test and we give them albuterol afterward to settle them back down, we bill both codes and usually get rejected for the 94640. Even though we use modifier -59 (distinct procedural service), many payers think the nebulizer treatment should be included in the 94070. Winter says that she always appeals these claims and is usually successful with the appeal.

The diagnoses for the methacholine challenge test and the aerosol inhalation treatment would have to be covered by ICD-9 codes under each policy. As with most procedures, there are limitations in each carriers policy to denote which diagnoses are covered and which are not.

Evaluation and management (E/M) codes (99201-99215 outpatient; 99221-99236 inpatient) can be billed in addition to the nebulizer codes if a separately identifiable E/M service was performed on the same day. Though not all insurers require it, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be added to the claim when billing the aerosol inhalations or the methacholine challenge codes on the same day as an E/M service, says Walter J. ODonohue Jr., MD, FCCP, representative to the American Medical Association (AMA) CPT advisory committee for the American College of Chest Physicians and chief of pulmonary/critical care at the University Medical Center in Omaha, Neb.

ODonohue also advises that practices bill 94640 if the bronchodilator treatment is repeated, by adding modifier -76 (repeat procedure by same physician) to the subsequent line items for 94640. In addition, you can also bill for the 94664 on the same day as the 94640, says ODonohue, if you are instructing the patient on how to use the bronchodilator themselves for the first time. If it is a reinstruction, code it as 94665 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; subsequent).

Documentation Must Be Precise

Practices billing nebulizer treatments must ensure that the patients medical record reflects medical necessity, including physician orders, plans of treatment, the patients response to treatment, and ongoing assessments of the patients need for treatment.

Some local Medicare carriers impose a three-day limit on respiratory therapy for acute phase patients per 30-day period. Practices should check with their insurance carriers to determine whether any special documentation rules or other guidelines apply to their nebulizer services.