Pulmonology Coding Alert

Also be on the lookout for a separately codeable education session

Stop missing opportunities to capture $15 for 94664 -- or coding it when you shouldn't -- by getting the lowdown on the pulmonary service's qualifying devices, documentation requirements and payment obstacles.

Do: Classify Advair Diskus Demo as 94664

Should you use 94664 for education/training with the Advair Diskus? asks Jen Krohn, CPC, CCP, coding specialist at Waukesha Health Care Inc. in Wisconsin.

Pulmonology Coding Alert went straight to the allergy experts to find out. Code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator,nebulizer, metered dose inhaler or IPPB device) "would seem appropriate to use for [Advair Diskus] demonstration and evaluation," says Gary N. Gross, MD, executive vice president of the Joint Council of Allergy, Asthma & Immunology.

Why: The Advair Diskus is an "aerosol generator," says Alan L. Plummer, MD,professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. Therefore, "teaching someone to use an Advair (or any other) Diskus does fall under 94664."

Example: A pulmonologist starts a patient with asthma (493.00, Extrinsic asthma;unspecified or 493.20, Chronic obstructive asthma; unspecified) on Advair. A nurse then teaches the patient how to use the Diskus. You should report 99201-99215 for the office visit and 94664 without a modifier, according to CPT guidelines, Plummer says.

CMS transmittal R954CP also indicates that modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) applies only to E/M services performed with procedures that carry a global fee, which 94664 does not have.

Beware: Before dropping 25 from 99201-99215 with 94664, check with your major insurers.

"Some payers may require modifier 25 appended to the E/M when performed with 94664 or any 'pulmonary' service," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Do: Include Dose in Teaching Session

During the teaching, the patient may receive a medication dose. In this case, Pohlig says, you should not separately report the treatment (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]).

Reason: The administration "was performed as part of the demonstration/evaluation, and the service's intent was patient teaching," Pohlig says.

If, however, the reverse occurs and the patient requires separate education after receiving an inhalation treatment, you may be able to bill both services.

"Typically, code 94640 does not include patient education," writes Steve G. Peters, MD, FCCP, in "Continuous Bronchodilator Therapy" published in the American College of Chest Physicians' Chest (2007; 131; 286-289).

"If separate medication instruction occurs on the same day as an initial aerosol treatment (e.g., a different form of inhaler requiring education), code 94664 can be used with a 59 modifier to indicate the distinct procedural service,"

explains Peters, who works at the Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine at the Mayo Clinic in Rochester, Minn.

Why: The Correct Coding Initiative (CCI) places a level-one edit on 94640 and 94664. So Medicare and payers that follow CCI edits may require modifier 59 (Distinct procedural service) on the component code (94664) to indicate that the teaching is a distinct procedural service from the inhalation treatment.

Example: During an outpatient visit, an asthmatic patient is wheezing and having difficulty breathing, which requires one or more bronchodilator treatments for intervention: 493.01, Extrinsic asthma; with status asthmaticus; 493.02, Extrinsic asthma; with (acute) exacerbation; 493.21, Chronic obstructive asthma; with status asthmaticus; or 493.22, Chronic obstructive asthma; with (acute) exacerbation.

Report 94640 (adding modifier 76, Repeat procedure or service by same physician, to separate line items of 94640 for multiple treatments) in addition to the proper E/M code without a modifier, unless the payer requires modifier 25 with the E/M, Plummer and Pohlig say.

"If the patient also needed education about the use of his MDI device, nebulizer, etc., during that visit (perhaps not using the device properly was in part responsible for the acute decomposition), then 94664 with a 59 modifier would also be coded," Plummer says. Typically, the medication provided for immediate intervention (a "rescue" medication) is different from the daily maintenance medication, for which the patient requires additional instruction.

"Unfortunately, not all payers will pay for 94664,"Gross adds. If practices abuse the code, probably fewer payers will pay the approximately $15 national rate (0.40 transitional nonfacility total relative value units x 38.0870 conversion factor = 15.23).

Solution: To support reporting 94664, documentation should include an indication of medical necessity,Gross says.

Example: To document the necessity for patient education, state in the Plan or Treatment portion of the written record that the patient requires a teaching session on the use of his MDI, diskus, nebulizer, etc. Experts also recommend noting why the session is needed. A statement could read, "The patient did not demonstrate the proper use of his MDI."