Pulmonology Coding Alert

Question: A pulmonologist performed a nebulizer demonstration during treatment for a patient’s asthma. Our claim reported 94640 with 94664 using modifier 59 on the nebulizer demonstration, but the claim was denied.

How can we correct the claim to receive reimbursement?

Codify Subscriber

Answer: The nebulizer demonstration, coded to 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device), is considered bundled into 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).

The situation may not warrant unbundling. If the demonstration and the treatment are occurring simultaneously, you should not unbundle the two services. However, if the treatment is provided and the physician prescribes a new inhaler for home use which requires additional patient demonstration, a modifier may be used to report both distinct services.

The edit pair of 94640/94664 has a modifier indicator of “1,” according to the Medicare National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits. So, when 94640 is a column 1 code, 94664 can be unbundled if appropriate with the correct modifier. You appended 94664 with modifier 59 (Distinct procedural service), but the payer may prefer one of the X{EPSU} modifiers.

X{EPSU} modifiers were established by Medicare in 2015 and provide greater specificity when reporting in situations where modifier 59 used to be used. Double-check your individual payer’s preferences to see if they require and accept an X{EPSU} modifier to unbundle the services. In this case, you could append 94664 with XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service).