Pulmonology Coding Alert

Talk to your physician to choose correctly between coding prolonged services or a higher-level E/M.

When your pulmonologist treats respiratory conditions such as asthma and emphysema with inhalation treatment, the decision to report a) only the nebulizer treatment, b) the appropriate E/M service, or c) a combo of both can make or break your practice’s bottom line. You may know that code 94640 covers inhalation treatment provided in the office, but do you know how to bill a nebulizer administration with an E/M service and/or demo?

Follow these four golden rules to remain on the right side of the audit fence while coding your physician’s inhalation treatment services.

Rule 1: Don’t Throw E/M Codes Out When Applying 94640

When your physician provides a nebulizer treatment in the office, you report code 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). However, don’t let an opportunity go to also get paid for the visit depending on the E/M service provided, because the two codes are not mutually exclusive.

Example: An established patient with emphysema presents complaining of shortness of breath, and determines the patient would benefit from an inhalation treatment. During the therapy, the physician trains the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision-making of low complexity. How should you report it?

In this case, you should report code 94640 to cover the inhalation service the physician provided. However, that’s not all. Because the physician also performed an office visit to assess the patient’s acute condition, which resulted in the decision for the nebulizer treatment, you can report 99213 (Office or other outpatient visit for the evaluation and management of an established patient….), based on your documentation of an expanded problem-focused exam with low-complexity decision-making. Treat the how-to discussion with the patient as part of the nebulizer administration. Attach 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) to 99213 to indicate that the E/M service was significant and separately identifiable from 94640.

Rule 2: Don’t “Double Dip” by Billing Treatment and E/M Together

Example: A patient requires two nebulizer treatments and lengthy treatment time due to hay fever with severely exacerbated asthma (J45.51, Severe persistent asthma with [acute] exacerbation). Should you report:

• codes 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity…) and +99354 (Prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure] in the office or other outpatient setting requires direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]) or
• just report a higher level E/M code 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components…)?

“This case will most likely qualify for a level four established patient office visit (99214) only,” cautions Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania. “You cannot report an E/M or prolonged care service based on the total time when the time represents procedures the physician is separately billing. This would be ‘double-dipping.’ The time it takes to perform a procedure or monitor for adverse effects of the procedures cannot be billed separately from the procedure code,” she adds.

Rule 3: Don’t Club 94640 and 94664 Together

Let’s consider the physician from the first example -- after performing an inhalation treatment -- determines that the patient’s plan of care should include inhalation therapy. The patient is new to this therapy and does not know the administration techniques involved in the procedure, so the physician provides a demo. This service is represented by code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) on the same day, but does Medicare allow this?

“No, Medicare doesn’t allow this pairing unless it is performed at a separate session, or involves instruction for new therapy not provided during the administration (e.g., a newly diagnosed asthmatic receives nebulizer therapy in the office, and requires training on the MDI added to his regime),” Pohlig says. Documentation would have to clearly outline these circumstances. If the training on the new therapy is minimal or brief, you may want to forego the billing since this would not support the additional service.

Remember that insurers consider 94664 a component of 94640. So, if you report 94640, you cannot also list 94664 and expect payment if the provider performed the two procedures on the same patient and on the same day. You would report only 94640 for the treatment, which also includes the training. But, if the patient only needed a review of educational issues concerning nebulizer use, you could use 94664 instead.

Rule 4: Bundle 94010 Into Bronchodilator Responsiveness Test

Spirometry comes lower in the code hierarchy than bronchodilator responsiveness test, since spirometry is performed pre-and post- bronchodilator administration. Both services (bronchodilator therapy and spirometry) are provided together in one session, but you only report the single code that combines this service, 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration).

Example: A patient receives nebulizer treatment and is evaluated for bronchodilation responsiveness to measure the patient’s response to the treatment. Should you separately report only the nebulizer?

No. You should only code 94060, which includes the nebulizer treatment. The National Correct Coding Initiative (CCI) bundles the inhalation treatment (94640) into 94060. The training/demo (94664) is bundled into 94060, as well.

CPT^® 94060 describes the spirometric evaluation procedure -- the measuring of the respiratory gases -- not evaluation of the patient’s condition, when performed. You would not use an E/M code (99211-99215, Established patient office visit) if the patient solely received the bronchodilation responsiveness test since evaluation of the patient’s immediate condition pre-and post-procedure is a inherent part of the procedural service.

Catch: Your nebulizer administration does not include the actual drug (e.g., albuterol) cost. Beware of this misunderstanding. If the drug represents a cost to your physician’s practice, and the service was performed in a private office setting, report 94640 and the drug separately (e.g., J7611, Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg).