Pulmonology Coding Alert

Use modifier76 to boost payments.

With the changes for inhalation therapy codes, you need to be a little more cautious when reporting these codes for treating acute airway obstruction. This advice applies to the treatment of Part B patients as a whole.

Implement the Revisions to 94640

Here is the revised instruction for 94640, with the 2016 changes in bold.

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.

(Do not report 94640 in conjunction with 94060, 94070 or 94400)

(For more than 1 inhalation treatment performed on the same date, append modifier 76 [Repeat procedure by the same physician]).

This clarification was needed “to be consistent with bundling edits do that people do not mistakenly report 94640 for the administration of the bronchodilator used in 94060,” explains Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania

She also states that “NCCI has added instruction for Medicare beneficiaries, and payers that follow NCCI Coding Principles, that more than 1 treatment should only be reported if provided at a separate single encounter.”

This means that for all Part B patients, including emergency room patients, you can bill 94640 only once for a single patient encounter, no matter how many times the patient receives inhalation treatment on that single visit. However, you may be able to bill for additional treatment performed during separate encounters for therapy by appending modifier 76 to 94640.

“Documentation is going to be key here to be able to bill for a 76,” cautions Alicia Scott, CPC, CPC-I, CRC, educational director with Certification Coaching Org., LLC. “For example, the patient was not able to complete the test physically and the provider needed to have it repeated.”

Pohlig also gives an example where “the patient returned to the office later in the day for a re-evaluation for increasing shortness of breath (having already been evaluated in the morning for an asthma exacerbation).If the physician determines that it is still treatable rather than sending the patient to the ER, he may provide another attempt at relief through the bronchodilator administration, and revising the plan of care to adjust the patient’s medication, or order nebulizer treatments at home.”

Keep bronchodilator evaluations and therapy separate: As per the new revisions, you must not code these along with 94640:

• 94060 — Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration
• 94070 — Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents (e.g., antigen[s], cold air, methacholine) 
• 94400 — Breathing response to CO2 (CO2 response curve).

Use the most time appropriate code: Remember to not bill 94640 with 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour) or +94645 (… each additional hour [List separately in addition to code for primary procedure]) on the same day. Decide which code to use based on the greatest volume/quantity and time duration.

These are time based codes,” says Jo-Anne Sheehan, CPC, CPC-I, CPPM, senior instructor with Certification Coaching Org., LLC. “For example, while 94644 pays $51.44, +94645 pays $16.46, and 94640 itself pays $21.46.”

Remember: “Be sure to check with each payer to identify if they follow the suggested NCCI guidelines, or defer to CPT^® instruction that doesn’t preclude reporting multiple inhalation treatments during one visit,” advises Pohlig. You must follow these revised guidelines to ensure you get properly reimbursed for your inhalation therapy services.

“To be your best advocate in these types of situations you need to keep communication open with a represented to the payer to understand what they require as well as the provider to be able to properly explain the reason behind a code,” explains Scotts. “Make sure you have a policy in place to handle specific codes that come through. These types of situations should be talked about in your office meetings so that everyone is on the same page. Education will mean a smooth transition for changes like these.”