Pulmonology Coding Alert

Question: An established patient with unspecified extrinsic asthma reports saying he is short of breath. The pulmonologist orders an inhalation treatment, then shows the patient how to use the nebulizer at home. The pulmonologist also performs an expanded problem- focused examination and medical decision-making of low complexity. Can we report more than one code?


Alabama Subscriber


Answer: In this case, you may be able to get paid for these three services using modifier 59 (Distinct procedural service). Here's how.

On the claim:

• report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key  components: an expanded problem-focused history, an expanded problem-focused examination, medical decision-making of low complexity) for the office visit.

• attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99213 to show that the E/M and the inhalation treatment were separate services.

• 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]) for the nebulizer treatment.

• report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered-dose inhaler or IPPB device) for the nebulizer instruction.

• attach ICD-9 code 786.05 (Shortness of breath) to 94640 to represent the patient's breathing difficulty.

• attach ICD-9 code 493.02 (Extrinsic asthma; with [acute] exacerbation) to 99213 and 94664 to represent the patient's asthma.

• attach modifier 59 to 94664 to show that the treatment and the instruction were two distinctly separate services. Rationale: If the physician decided to place the patient on home nebulizer treatments after determining satisfactory response to the in-office treatment, the education/training conducted is separate from the provided inhalation therapy.