Pulmonology Coding Alert

Question: When an established patient with emphysema presents complaining of shortness of breath, what CPT code should I report? The physician provides inhalation treatment, teaches the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision-making of low complexity.

Montana Subscriber

Answer: You would need to report more than one CPT code in this case. First, you should use 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 all-encompassing service the physician provided. This code also depicts that the physician's main intent was to treat the acute obstruction.

The office visit would warrant the code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity.) based on your documentation of an expanded problem-focused exam with low-complexity decision-making. You might require to append 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 indicate that the E/M service was significant and separately identifiable from 94640 since the evaluation was warranted and led to the decision to treat the patient.

You don't need to bill 94664 since it is a component of 94640. If you bill 94664 (Demonstration and/ or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) with 94640 on the same day to Medicare, see to it that you justify that the doctor provided the 94664 service distinctly separate from the treatment (e.g., instruction on a medication different from the one administered -- the physician prescribed a new metered dose inhaler after discontinuation of the nebulizer). In this case, you should add modifier 59 (Distinct procedural service) to 94664 to notify the payer that the pulmonologist carried out 94664 separate from 94640. The documentation should include details on the medical necessity for separately providing this service.