94640 Neb Question- Pls Help!

[marissa487]

I'm new in the coding field and I keep seeing the same issue within my practice, whenever I bill for a nebulizer treatment with an E/M service (99211-99214) the neb is paid (or dropped as a deductible to the patient) and the E/M is globaled out with a zero pay. I must not be billing this service right, I have tried it a few ways, with a few different modifiers but nothing I do is able to get the E/M AND the nebulizer paid for. Has anyone else come across this or have any suggestions? Please help!!!
(PS I work in Pediatrics, not sure if this makes a difference)

[jettman]

Originally Posted by marissa487

I'm new in the coding field and I keep seeing the same issue within my practice, whenever I bill for a nebulizer treatment with an E/M service (99211-99214) the neb is paid (or dropped as a deductible to the patient) and the E/M is globaled out with a zero pay. I must not be billing this service right, I have tried it a few ways, with a few different modifiers but nothing I do is able to get the E/M AND the nebulizer paid for. Has anyone else come across this or have any suggestions? Please help!!!
(PS I work in Pediatrics, not sure if this makes a difference)

Marissa, have you tried attaching Modifier 25 to the E/M codes? Are all payers denying the E/M service or just a few?

I assume (dangerous to assume, I know) that you are coding and billing professional charges, not facility charges, correct? I'm not aware of 94640 carrying global days and indeed, there are no issues with NCCI edits when I checked it against a few E/M codes.

If I may offer some advice, it would be to check your specific payer contracts to see if there are any exclusions. If not, it would be worth a phone call to the plan rep asking for a valid denial reason.

Best of luck,
Jettman

[corikr77]

I am fairly new to coding in family practice as well and need clarification on this please. So if a patient comes in for an e/m for asthma only and the e/m and nebulizer treatment is documented, can we still attach modifier 25 even though the reason for the visit and the treatment were for the same reason? I appreciate your help!

Cori Rocks, CFPC, CPC-A

[lisamgoguen]

See, the nebulizer (94640) and E/M are both paid roughly 95% of the time without issue whrn I use modifer 25 on the E/M.

What I have an issue with is when billing 94760 in addition to 94640. I have been using modifier 59 on 94640 in this case and so far, so good.

The other issue I have is when billing for multiple 94760. They always seem to deny one or both as inclusive. I am wondering if I should be billing with modifier 76, or increasing units. Any thoughts?

Thanks,
Lisa

[mitchellde]

You bill the second and subsequent neb with the 76, however you cannot add the 59 to the pulse ox unless documentation supports these were 2 separate instances. if the pulse ox were performed at the same time as the neb then you cannot support the use of the 59 as they are bundled services.
CORI:
Yes you may use the 25 on the office visit even if you have only one dx. look in appendix A of the AMA CPT book under the 25 modifier it states:
"...As such separate dx are not required for the use of the 25 modifier"

[lisamgoguen]

Originally Posted by mitchellde

You bill the second and subsequent neb with the 76, however you cannot add the 59 to the pulse ox unless documentation supports these were 2 separate instances. if the pulse ox were performed at the same time as the neb then you cannot support the use of the 59 as they are bundled services."

This is very good to know! Example of how the office currently sends over for scrubbing

94640.59
94760
94760.76

This usually pays both the neb treatment and the first pulse ox. and then denies the second as inclusive. When there is no modifier 59, they do not pay either pulse ox.
And, what I am reading says it should be billed like this...

94640
94761

Does this look right?

[mitchellde]

just bill the 94640, the pulse ox will bundle, check the CCI edits.

[lisamgoguen]

Originally Posted by mitchellde

just bill the 94640, the pulse ox will bundle, check the CCI edits.

Thanks!

The other question... provider also bills for the albuterol used. Medicaid will not pay now stating it is a DME code... any thoughts?