Pulmonology Coding Alert

Once again, CMS listed J7613 as the most-billed code.

Although you may think E/M services are the bread and butter of pulmonology coding — and of codes billed to Medicare in general — the reality is that HCPCS Level II codes bring in a tremendous amount of money from Medicare as well.

Background: CMS data 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 in 2019 (the most recent year for which CMS reported the information). It represented the most allowed HCPCS Level II codes last year at 249 million, racking up nearly $11 million in charges. Not only that, but 2019 marked the fifth year in a row that J7613 was the most-reported HCPCS Level II code.

In addition, J7677 (Revefenacin inhalation solution, fda-approved final product, non-compounded, administered through DME, 1 microgram), a code that just debuted in July of 2019, ranked second on the list of most-reported supplies during the year that it launched. The medication is often used for patients with chronic obstructive pulmonary disease (COPD). This code represented over $41 million in allowed charges for the year.

Ranking fifth on the list of most-billed HCPCS Level II codes to Medicare in 2019 was J7620 (Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME), with 124 million allowed services.

Chances are strong that your pulmonology practice ranked among the offices submitting at least one of these codes. For a quick primer to make sure you are reporting these medications properly, read on.

Remember to Report Administration Codes

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 16-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 patient recovers, you prescribe a new inhaler. A nurse demonstrates proper inhaler technique, has the patient 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.

How to: Separate the documentation for each distinct service, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

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.

Watch Units for J7677

When it comes to the relatively new code J7677, ensure that you’re reporting the correct number of units when you report this service. You’ll submit one unit of the code for every microgram administered.

“The recommended dose of revefenacin inhalation solution is administered once daily via a standard jet nebulizer,” says Part B payer CGS Medicare in a news alert about the code.