Pulmonology Coding Alert

Question: An established patient with chronic obstructive bronchitis reports to our office for a scheduled nebulizer training session. An advanced registered nurse practitioner (ARNP) provides the patient with training on how to use the device under direct physician supervision. Can I report an E/M and a procedure code?

North Dakota Subscriber

Answer: In this instance, you cannot code a separate E/M. Since the patient was scheduled for nebulizer training, and that is the only service the ARNP provides, that is the only service you can code.

Report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) for the encounter. Also, append 491.20 (Obstructive chronic bronchitis; without exacerbation) to 94664 for the patient's diagnosis.

Scenario change: If the ARNP provides service outside of the nebulizer education during the encounter, you might be able to report a separate E/M.

Example: An established patient reports to the pulmonologist's office for nebulizer training. The ARNP provides the patient with guidance on using the device. The patient then tells the ARNP that he has been having serious headaches and dizzy spells lately. The ARNP checks out these symptoms for the patient and provides guidance on treatment (a level-one E/M service).

In this case, the ARNP provides the training, then addresses the patient's separate issue (headaches and dizziness) with an E/M service.

In this instance, you would report the following:

• 94664 for the training

• 466.0 appended to 94664 for the patient's acute bronchitis

• 99213 for the E/M

• 784.0 (Headache) linked to 99213 for the patient's headaches

• 780.4 (Dizziness and giddiness) linked to 99213 for the patient's dizzy spells

• Modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99213 to show that the E/M and training were separate services.

Remember: Since the ARNP treated a new problem in this example, you cannot bill this visit incident to the physician. Be sure you code the visit under the ARNP's National Provider Identifier (NPI).

-- The answers to the Reader Questions and You Be the Coder were provided or reviewed by Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Health-care Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.; Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy and critical care at Emory University School of Medicine in Atlanta; and Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.