Pulmonology Coding Alert

Find out why E/M + modifier 25 is not a solid equation.

When you're coding for spirometry testing, it's important you know the difference between the more common coding options.

You should always ask the one critical question that can turn your selection process into a success: "Which of the spirometry codes do I need to include in my claim, and which of them should I discard?"

The scenario: An established patient presents to the office for a follow-up visit after experiencing mild dyspnea where she was given a nebulizer or inhaler treatment. The pulmonologist also evaluates the patient's respiratory status at that visit to determine the cause for dyspnea.

Don't Leave Out the Possibility of Reporting 94664 Sometimes patients who regularly use inhalers need to learn how to use the device correctly. If the staff ran a demo on how to use it properly, you have the option to report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

Example: A pulmonologist implements a care plan for a patient with asthma (493.00, Extrinsic asthma;unspecified or 493.20, Chronic obstructive asthma; unspecified) using Advair Diskus. A nurse then shows the patient how to use the device.

You should report 99201-99215 for the office visit and 94664 -- without a modifier.

The Advair Diskus is an "aerosol generator," says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. Specifically, Advair Diskus is a powder form of fluticasone and salmeterol that's packaged with a special inhaler device pre-loaded with blister packs containing measured doses of the medicine.

Modifier 25 is not necessary when reporting 94664 with an office visit because CMS indicates that this modifier applies only to E/M services performed with procedures that carry a global fee. CPT 94664 does not have a global fee.

Safety measure: Since some payers would still require appending modifier 25 to an E/M when performed with 94664, it's important that you check with insurers about their policy. The medical staff may administer a medication dose to a patient during the teaching session. In this case, you should report the most comprehensive service. When dose is administered as part of a demonstration, its intent is -- obviously -- to teach the patient. Thus, reporting 94664 is more appropriate. When the intent is to deliver a medication dose to someone who is having difficulty breathing, report 94640 instead.

Look Out for Bronchodilator Requirement

If the encounter involved bronchodilation, report 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre-and post-bronchodilator administration). It is the correct code to use when a pulmonologist interprets a graphic reading before and after a nurse or a medical technician administered a bronchodilator.

Remember: Code 94060's values include three items: prebronchodilation measurement, bronchodilation, and postbronchodilation measurement. This code calls for direct supervision of the physician. See to it that a doctor is present in the office suite and is readily available to guide and provide assistance throughout the procedure.

94010: Independent vs Integral

You should use 94010 (Spirometry, including graphic record, total and timed vital capaticy, expiratory flow rate measurement[s], with or without maximal voluntary ventilation), which describes the spirometry test, along with an E/M code such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient) to describe the office visit.

Payers often require you to append modifier 25 (Significant, separately identifiable E/M service) when the pulmonologist completes a service in addition to the E/M, but it is not correct coding to do it with 94010, or another spirometry code 94016 (Patient-initiated spirometric recording per 30-day period of time; physician review and interpretation only).

Why: As modifier 25's descriptor suggests, you should append the modifier to an E/M service code, when provided with another service or procedure on the same day. Diagnostic testing, such as code 94010, is considered exempt from this concept since it does not have a global period of 0- day or 10-day.

Bottom Line: Payers may disregard correct coding principles in this case, and require you to append modifier 25 to the E/M when reported with spirometry. For some payers that is the only way to electronically allow payment for two different service types on the same claim.

Caution: Be sure not to report 94010 when the patient receives a bronchospasm evaluation (94060) since spirometry is a required component of 94060.