Pulmonology Coding Alert

Find out whether you can find the right codes for these common services.

As a pulmonology coder, it's likely that you see charts for breathing treatments every day, and you probably know most of the codes for these services by heart. But some doctors' reports can throw a wrench in the works by adding additional services or falling short of the standard CPT® descriptors, forcing you to find an alternate code or use a modifier.

To get a handle on where your breathing treatment coding stands, check out the following examples and then determine which codes you'd select to report the services.

1. Spirometry with pre- and post-bronchodilator

An established patient presents for a follow-up visit after an episode of respiratory distress with wheezing where she needed a nebulizer or inhaler treatment. The pulmonologist evaluates the patient's respiratory status, including spirometry and discussing further management. The pulmonologist then treats the patient with an inhaled bronchodilator, and conducts a follow-up spirometry test to evaluate whether it changed her breathing and to determine whether the patient has asthma.

Question: Which code should you report among the following?

    A. 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation)
​    B. 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration)
​    C. 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)
​    D. 94010 x 2, 94640

Answer: Your correct answer is (B), code 94060. That's because 94060 includes both the bronchodilation and both spirometry tests (before the bronchodilation and after). In most cases, you will also report the appropriate E/M code 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 to it along with 94060.

"A modifier 25 is required when there's an E/M visit and a procedure is provided during that encounter," said SharonNicka, RN, CPC, of Nicka Medical Coding Solutions in McKinney, Texas. "Without the 25 modifier, it will not be paid."

Reporting answer (D) is incorrect because a more comprehensive code (94060) exists to better describe this service as an all in one service. In addition, reporting either (A) or (C) would cause you to only describe part of the service, since each of these options leaves off part of the doctor's work.

2. Know How to Code Diskus

The pulmonologist examines an established patient during a level three office visit. The patient does not feel that her current asthma prescription is working, so the doctor prescribes the patient with Advair as her new treatment format. He then teaches the patient how to use the Diskus inhaler so she'll know how to use it at home.

Question: Which code should you report among the following?

    A. 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)
    B. 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction, first hour)
    C. 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device)
    D. 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management)

Answer: The correct answer is (C), 94664, because this code describes the clinician's demonstration of the Diskus, which is a metered dose inhaler. Although code 94640 may seem appealing because it refers to treatment with a metered dose inhaler, it doesn't describe the educational aspect of the service that the physician performed. And though codes 94644 and 94660 describe services for breathing treatments, they are for different services and do not reflect the work of showing a patient how to use an Advair Diskus.

In this case, you should also report 99213 (Office or other outpatient visit for the evaluation and management of an established patient...). Because code 94664 doesn't have a global period, many insurers don't require you to append modifier 25 to the E/M code when reporting these services together. However, some private insurers and state Medicaid carriers deny claims for these services when billed together without modifier 25. Therefore, you should typically append modifier 25 to the applicable E/M code when reporting these services on the same date of service. For instance, in this scenario you'd report 94664 followed by 99213-25.

3. Bronchodilator With Education

An asthmatic patient presents with wheezing and difficulty breathing during an outpatient visit. She requires a nebulizer treatment for intervention. During questioning, your physician discovers that the patient hasn't been using her metered dose inhaler device properly prior to her visit. After he treats the patient, he providers her with additional education about how to use the metered dose inhaler.

Question: Which code should you report among the following?

    A. 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)
    B. 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device)
    C. 94640 and 94664
    D. 94664 and 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction, first hour)

Answer:  The correct answer is (C) since you'll report both 94640 and 94664 for this service. You should append modifier 59 (Distinct procedural service) to code 94664, because the Correct Coding Initiative (CCI) bundles this code into 94640. The modifier demonstrates the fact that the patient required additional instruction for his daily maintenance medication, which is different from the aerosol provided for immediate intervention (94640).

Reporting either 94640 or 94664 alone will force your pulmonologist to take a pay cut, since the practice deserves payment for both codes in this scenario, assuming the documentation clearly demonstrates the separate and distinct nature of the different services.

You should also report the appropriate E/M code, but may need to append modifier 25 to it so you can demonstrate that it was significant and separately identifiable from the treatment (94640) and education (94664). The E/M resulted in the plan for these other services. Some payers require you to add modifier 25 in this situation, while others would not require it. It is always important to check with your top payers for their specific regulations.

Bonus Question: Asthma Education

The pulmonologist spends about 15 minutes working with a patient on how to use her nebulizer and other asthma devices so she can understand exactly how to manage her asthma symptoms.

Question: Which code should you report among the following?

    A. 99212 (Office or other outpatient visit for the evaluation and management of an established patient...)
    B. 99401 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual [separate procedure]; approximately 15 minutes)
    C. 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device)
    D. 99204 (Office or other outpatient visit for the evaluation and management of a new patient...)

Answer: The correct answer is (C), 94664. Although many practices immediately reach for 99401 for this service, it is typically not appropriate in a scenario like this. CPT® says that 99401 is for "persons without a specific illness for which counseling might otherwise be used as part of treatment." Since your patients have asthma, you're better off reporting 94664 if you're doing education on how to use the nebulizer or aerosol puffer.