Pulmonology Coding Alert

Solve 94640 Denial Using These Tools

Question: I reported a sick visit in which a strep test and nebulizer treatment were performed as follows:

• 99213  diag: 465.8/519.11
• 87880  diag: 465.8
• 94640  diag: 519.11.

The insurer denied the nebulizer treatment due to an incorrect procedure code or diagnosis. What am I doing wrong? Does the office visit need a modifier?


New York Subscriber


Answer: Try using a modifier on two codes and reordering the codes in order of importance.

First: CPT does not require you to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when you code an office visit (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) and nebulizer 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]).

But the insurer may have a software edit that causes a denial unless the modifier is used, so try attaching modifier 25 to 99213 to indicate the service is significant and separately identifiable from the nebulizer treatment.

Next: The strep test (87880, Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A) is a Clinical Laboratory Improvement Amendments-waived test, which means you need a certificate of waived status to perform the test in your office. To indicate that you have waived status, many insurers require you to append the lab code with the Medicare modifier QW (CLIA waived test).

Because 87880-QW is usually associated with diagnosis 462 (Pharyngitis), you should relook at the reported ICD-9 code (465.8, Acute upper respiratory infections of multiple or unspecified sites; other multiple sites); 87880-QW performed for reasons other than a sore throat is considered "not medically necessary" and causes a denial.

Also: Some payers do not reimburse 87880, considering it part of the E/M service. 

Finally: Payers often expect to see CPT codes in descending order starting with the most significant service or procedure first. Try reordering the test, listing the nebulizer treatment before the lab test.

Make sure the diagnosis represents the indication for each service: 465.8 linked to the E/M service (99213-25), and 519.11 (Acute bronchospasm) linked to the office visit (secondary) and the nebulizer treatment (94640).

You could report as a secondary diagnosis 465.8, with the nebulizer, as the underlying cause of the bronchospasm. The optimal coding would be:

• 99213-25 -- 465.8/519.11
• 94640 -- 519.11/465.8
• 87880-QW -- 462.