Pulmonology Coding Alert

There has been much confusion in the past regarding coding for the use of nebulizers as opposed to multidose inhalers (MDIs). Coders questioned whether MDIs were considered nonpressurized and included under 94640. The current changes were made to clarify the use of aerosols and bronchodilators and also to grow with current medical practice.

The intermittent positive pressure breathing treatment codes (94650-94652) have been deleted and are included in 94640. Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the department of medicine at the University of Pennsylvania in Philadelphia, states that these decisions make logistical sense because now CPT separates the diagnostic and therapeutic services (94640) from the patient-education services (94664). Prior to the 2003 change, the diagnostic sputum induction was lost in 94664.

For instance, a 58-year-old man presents in the office with increased difficulty breathing. Since he is not having an acute problem such as an asthma attack, the pulmonologist needs to determine what is causing the condition. A nebulizer treatment is given to induce sputum, which will then be evaluated. The sputum is tested for bacteria, viscosity, color or smell. In this case, the nebulizer is used for diagnostic purposes only. In the past you coded 94664. Beginning in 2003, however, you will need to code 94640 because the diagnostic aspect will be included with the treatment for acute problems.

In another scenario, Anthony Marinelli, MD, FCCP, chairman of the American Thoracic Society's Clinical Practice Committee, describes a 70-year-old with obstructive emphysema (492.8) who is seen for the first time in your office. You decide to prescribe a metered-dose inhaler and instruct the patient on the proper use of the MDI (94664). You have already performed a history, physical exam and medical decision-making. You would bill for the E/M visit with 99241-99245 if the visit is for a consultation or 99201-99205 if the E/M is a new patient visit.

Be sure 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 office visit code and report 94664 separately. The patient returns one month later for a follow-up visit. You again take a history, perform a physical exam and undertake medical decision-making. You determine that she has not improved on her current therapy, and you decide to prescribe nebulizer therapy for home use. You would bill 99211-99215 with modifier -25 for the E/M and 94664 to report the demonstration or evaluation of the nebulizer therapy.

Code 95027 (Skin end point titration) now has a new refurbished definition that adds more specificity to clarify the code's usage. The revised code reads, "Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, specify number of tests."

The definition of the code was changed to make it more consistent with other allergy diagnostic testing codes and to distinguish it from similar codes, such as 95015 (Intracutaneous [intradermal] tests, sequential and incremental, with drugs, biologicals, or venoms, immediate type reaction, specify number of tests).

According to Teressa Kelly, practice manager, Alabama Asthma & Allergy Clinic, coders will need to review this change carefully because it has been common practice to use 95024 for intradermal testing. The difference is that 95027 pertains to a specific category of allergens those that are airborne. The terms "sequential and incremental" are also distinguishable features in that you may provide more than one dilution of the extract.

1. Modifiers. You can no longer use a separate five-digit code in place of a modifier. For example, you cannot substitute the code 09925 for modifier -25. This rule has been applied to all modifiers.

Also, a new modifier has been added: modifier -63 (Procedure performed on infants less than 4 kg). This change was made because procedures performed on low-body-weight infants are more complex than other procedures. This modifier is to be used on codes 20000-69999 only, not on E/M or Medicine codes.

2. Critical Care Services. There will be some drastic changes to the neonatal critical care codes, along with the addition of a new code for pediatric critical care. Five codes are affected: