Pulmonology Coding Alert

Get what you deserve with 94664 and 9921x

The next time your practice drops everything to treat an unscheduled patient for wheezing, don't run for the waiting room. Instead, take a deep breath and use these expert tips for billing the training and the office visit.
 
When treating a wheezing patient (786.07), a pulmonologist can spend hours performing procedures - such as pulse oximetry, spirometry, inhalation treatments and training - and services - including patient history, examination and medical decision-making. If you fail to code for the training and all E/M services, your practice will sacrifice reimbursement. On the other hand, using 99214 or 99215 (Office visit for an established patient) inappropriately could raise red flags and result in charges of fraud.

Treatment Does Not Include Training

Many pulmonary physicians wonder whether a nebulizer treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) includes training on the inhaler. Code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) is not a treatment, coding experts say. That's because patients can perform the service themselves.
 
Much of this confusion stems from the earlier definitions of 94664 (Aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) and 94665 (... subsequent) clarified in CPT 2003. The helpful language eliminates the term "initial" and adds "patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device." And, CPT eliminated 94665. These changes clarify that 94664 refers to an inhaler demonstration. "Code 94664 does not include the services described by code 94640," states CPT Assistant, April 2000.

Report 94664 for Physician-Supervised Training

For the nurse training, you should report 94664. The 2003 National Physician Fee Schedule Relative Value File requires direct physician supervision for 94664. If a member of the office staff demonstrates how to use the nebulizer under direct supervision, use 94664 rather than 99211 (Established patient office visit ...), says Victoria S. Jackson, owner of Omni Management, which provides practice management services for 15 medical offices in the Los Angeles area.
 
To meet direct-supervision requirements, the physician must be physically present in the same office suite and immediately available to render assistance if necessary.

Fight NCCI Training and Evaluation Edits

Individual payer policies may cause many pulmonologists to think that 94640 includes training. The National Correct Coding Initiative (NCCI) bundles nebulizer training (94664) into bronchospasm evaluations (94060). So some practices may receive denials for 94664 from payers that follow NCCI edits.
 
Some third-party payers allow 94664 once per year. But this ruling reflects 94664's prior definition as an "initial" training session. CPT 2003's deletion of 94665 and the term "initial" from 94664 should clarify that 94664 applies per training day.
 
For carriers that bundle the training or add other exclusions, such as one training per year, you should aggressively appeal these edits based on the CPT codes, says Richard H. Tuck, MD, FAAP, medical director of quality care partners, PrimeCare of Southeastern Ohio in Zanesville. "You should challenge any carrier that bundles the initial training or the treatment as inclusive in the E/M service."
 
For the training, applicable codes include 94664; if the payer accepts 94664, bill it with an E/M code (include the training in the office visit, 9921x) and appeal.

Pre- and Postevaluation Deserves an E/M

You will often report an E/M in addition to 94060, coding experts say. If the office visit is to review the set of problems, and the airway function evaluation is to assess the severity of the problem, you should report both the service and the procedure. "The E/M is looking at the whole picture of the patient in the context of the problem," Jackson says. "Code 94060 is quantifying a particular issue for the physician."
 
Most payers require you to append the E/M code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate a separate E/M service from the nebulizer treatment, coding experts say. Some payers may not require modifier -25, making billing for these services easier. Therefore, know your payers and their billing policies.
 
For some carriers, you can report the procedures appended with modifier -59 (Distinct procedural service)
and the E/M without a modifier. "The patient came in for the visit, not the spirometry and inhalation treatment," Jackson says. Modifier -59 appended to the spirometry and inhalation treatment appropriately describes the procedures as distinct procedural services from the E/M.