Pulmonology Coding Alert

Question: Which CPT code should we report when an established patient with emphysema (492.8, Other emphysema) presents complaining of shortness of breath (786.05)? The physician provides inhalation treatment, trains the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision-making of low complexity.


Alabama Subscriber


Answer: You'll need more than one CPT code for this encounter. Report 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]) to cover the comprehensive service the pulmonologist provided.

Because the physician also performed an office visit, you should also report 99213, based on your documentation of an expanded problem-focused exam with low- complexity decision-making.

You may also report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) since the pulmonologist or the staff showed the patient how to use the nebulizer when at home.

However, if you bill 94664 along with 94640 on the same day to Medicare, make sure you justify that the physician provided the 94664 service distinctly separate from the treatment. In this case, attach modifier 59 (Distinct procedural service) to 94664 to notify the payer that the pulmonologist performed 94664 separately from 94640. The documentation should include details on the medical necessity for providing this service separately.

Example: The pulmonologist determined that the patient's plan of care should include nebulizer therapy, or the patient is new to this therapy and does not know the administration techniques involved in the procedure.

The note should clearly identify that the physician or the staff demonstrated use of the equipment to the patient separately from the treatment administration. Otherwise, the insurer may think you are trying to report one service twice.
 
Tip: Though technically not required, it may help to link separate diagnosis codes for the E/M visit and the nebulizer treatment. For instance, you could link 786.05 (Shortness of breath) to 94640, and link the emphysema code (492.8) to 99213.