Pulmonology Coding Alert

CMS lists J7613 as last year’s most-billed code.

When most pulmonology practices think of their top-billed codes, they’re quick to consider E/M services and pulmonary function tests. But when you go beyond CPT® codes, you may realize that you’re frequently reporting HCPCS services.

That’s the word from CMS data, which indicates that J7613 (Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg) was the number one code among all Part B physician/supplier data. It represented the most allowed services last year at 271.7 million, racking up over $12.5 million in charges.

On that same list, J7620 (Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME) ranked third, with 130.5 million allowed services last year.

Chances are strong that your pulmonology practice ranked among the offices submitting this code last year, as well as in 2019. For a quick primer to make sure you are reporting this code properly, read on for a few best practices.

You’ll Almost Never Report Albuterol Alone

Your practice will probably never bill an albuterol “J” code by itself — and if you find yourself doing this frequently, there’s a chance you could be missing out on payment. That’s because the albuterol is usually administered during a breathing treatment, which is separately billable using a CPT^® code.

Example: An established asthmatic 12-year-old patient presents to your office with increased symptoms. You evaluate the patient and administer a nebulizer treatment using a unit dose of albuterol. After the child recovers, you prescribe a new inhaler. A nurse demonstrates proper inhaler technique, has the child practice using the inhaler, and corrects the patient’s misuse. 

Solution: You’ll report the following CPT^® codes for this service:

• 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended for the office visit. 
• 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) for the nebulizer service
• 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) with modifier 59 (Distinct procedural service) attached for the training.
• J7613 for the albuterol.

You’ll also submit J45.31 (Mild persistent asthma with (acute) exacerbation) as the ICD-10 code that supports the above codes.

If insurers bundle 94664 into 94640, separate documentation could help you overturn denials. The pulmonologist should clearly document the demo of the new inhaler and the nebulizer treatment as separate procedures in the progress notes, in addition to using modifier 59 on the claim, advises Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

How to: Use one paragraph for the treatment and another paragraph for the training with the corresponding treatment/supply details. This visually shows an insurer that each procedure is different. Often, a nurse performs the demonstration as part of the pulmonologist’s services.

Payers Are Watching

Although you might think albuterol represents a small expense to the Medicare program, that doesn’t mean insurers aren’t hoping to curb costs on the medication. An OIG report several years ago noted that “Medicare pays too much for albuterol,” and some payers have these codes under review.

In 2016, CGS Medicare placed five albuterol drug codes (including J7613 and J7620) under prepayment review due to “a high claims payment error rate for this product category.”

Thereafter, all claims submitted for this service were reviewed for additional documentation to ensure that they included a detailed written order, relevant medical records to support medical necessity, proof of a refill request, and any other pertinent records including information related to continued use of the medications.

Practices who didn’t submit this information within 45 days of the claim date found their albuterol services denied.

Therefore, go back over your albuterol claims to ensure that you’ve got the appropriate documentation on hand. If you’re ever asked for documentation to support your claims, you’ll have the confidence that you’re covered.

Resource: To read the most-billed Medicare services, visit  www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareFeeforSvcPartsAB/Downloads/Level2Serv18.pdf.