Pulmonology Coding Alert

Question: What CPT code should we report when an established patient with emphysema (492.8, Other emphysema) presents complaining of shortness of breath (786.05)? The pulmonologist 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 physician provided.
 
Because the physician also performed an office visit, you should also report 99211-99215 (Office or other outpatient visit for the E/M of an established patient).
 
Report 94640 instead of 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) since the pulmonologist's primary intent was to treat the obstruction.
 
Caution: If you bill 94664 along with 94640 on the same day to Medicare, make sure you justify that the pulmonologist 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 separate from 94640.
 
The documentation should include details on the medical necessity for providing this service. Example: The pulmonologist determined that the patient's plan of care should include inhalation 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 pulmonologist demonstrated the inhaler to the patient separate from the administration for treatment. 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 to the E/M and the nebulizer treatment. For instance, you could link 786.05 (Shortness of breath) to 99213, and link the emphysema code (492.8) to 94640.