Don’t Leave Money on the Nebulizer Table
Breathe a sigh of relief in knowing you are confident in inhalation treatment billing.
By Ken Camilleis, CPC, CPC-I, CMRS, CCS-P
There are many services and products that may be billed when a patient presents with chronic asthma or other serious respiratory conditions, or acute exacerbation of related symptoms. Physicians must capture all pertinent information in their documentation and, in turn, coders (or those who validate pre-coded electronic health record charges) must account for all related services, medications, and supplies.
In ICD-9-CM, a code from chapter 8 (Diseases of the Respiratory System) will be the primary (and often, only) diagnosis reported. In ICD-10-CM, a primary code from chapter 10 (Diseases of the Respiratory System) is indicated.
Some respiratory or pulmonary conditions may qualify for inhalation (aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing) treatment coding, such as:
- Asthma (ICD-9-CM 493.90, ICD-10-CM J45.-)
unspecified, with status asthmaticus (493.91, J45.902)
- Acute bronchitis (466.0, J20.-)
- Other chronic obstructive pulmonary disease (COPD) (496, J44.9)
- COPD with (acute) exacerbation (491.21, J44.1)
- COPD with acute lower respiratory infection (491.22, J44.0)
- Pneumonia (486, J18.-)
- Bronchopneumonia (485, J18.0)
- Acute bronchospasm (519.11, J98.01)
- Cough (786.2, R05)
- Wheezing (786.07, R06.2)
- Shortness of breath (786.05, R06.02)
As we convert to ICD-10, physicians must capture all relevant information regarding the patient’s respiratory condition, and coders must be adept at picking up details to properly report the expanded inhalation treatment diagnostic codes.
Capture All Relevant
Procedures, Services, and Supplies
Five services and products are reported in a typical inhalation treatment encounter:
- Separately identifiable office visit
- Inhalation treatment
- Pulse oximetry (oxygen saturation)
- Medication dispensed
- Nebulizer mask/administration set
Although reimbursement for these items is based on specific payer guidelines (not all payers will reimburse for all services), failure to account for any of the above services and products, when covered, will result in lost revenue.
Take a Closer Look at the Five Items
Office visit (99201-99215) ‒ The patient is examined to achieve a diagnosis and to conduct or prescribe a treatment plan. The doctor needs to listen to lung sounds and observe a variety of findings. When the provider performs other, separately coded procedures or services during the same encounter, you must append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service to the visit code. If the patient is scheduled solely for inhalation treatment, no office visit is reported.
Inhalation treatment (94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (eg, with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device)) ‒ This is the component of treatment that potentially improves the patient’s condition, or even eliminates ongoing symptoms.
Oxygen saturation (O2Sat) (94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination) ‒ An O2Sat is routinely performed as a preliminary step to assess a patient’s condition. Even a persistent cough with no definitive diagnosis may justify a separately billable O2Sat. Based on the results of the O2Sat, the physician may decide the patient warrants further (possibly immediate) services, such as inhalation treatment. Although this code does not create a Column 2 National Correct Coding Initiative edit, some payers may want modifier 59 Distinct procedural service appended to the secondary procedure.
Medication provided (e.g., J7613 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg, or J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME) ‒ When nebulizer treatment is provided, a medication is expended. Because the medication is dispensed in the doctor’s office (place of service code 11), the practice is allowed to bill for the drug separately.
Documentation must indicate:
1. The type and concentration of the agent; and
2. The specific dosage of each constituent.
For instance, J7620 describes albuterol and ipratropium, with unit dosages of 2.5 mg and 0.5 mg, respectively. Code J7620 is often called a “DuoNeb” because the nebulizing product is a combination of two medication agents. For higher doses, if supported by medical necessity, you may report J7620 x 2 (or more).
Nebulizer mask (A7003 Administration set, with small volume nonfiltered pneumatic nebulizer, disposable) ‒ Because a nebulizer mask is used only once by one patient, report only one unit. The payer may want modifier NU New equipment appended for a new purchase. Documentation must support that the item was provided to the patient at the time of treatment. When the medication and mask are provided in the doctor’s office, there is no charge for the use of the nebulizing machinery (e.g., E0570 Nebulizer, with compressor) because this is rolled into the visit.
For example, a patient with coughing, wheezing, and shortness of breath arrives at the emergency room (ER). She is tested and discharged without a definitive diagnosis. Several weeks later, her primary care physician refers her to a pulmonologist. The pulmonologist performs a detailed history and exam with moderately complex medical decision-making, including an O2Sat, and diagnosis the patient with COPD. He administers a dose of 1 mg albuterol in concentrated form, non-compounded. The O2Sat was instrumental in confirming the patient’s diagnosis. The O2Sat (94760) and inhalation treatment (94640) are separately billable, as is the nebulizer mask (A7003). The proper HCPCS Level II code for the medication is J7611 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg.
Other Services and Conditions
Additional billable services may be provided. For example, a maximum breathing capacity/maximum voluntary ventilation study (94200 Maximum breathing capacity, maximal voluntary ventilation) may be performed at the same session. Some payers may require billing the technical and professional components separately with modifiers TC Technical component and 26 Professional component.
For example, a patient who has suffered asthma attacks over the past six months is diagnosed with acute exacerbation of asthma, confirmed by an O2Sat. A maximal voluntary ventilation (94200) and nebulizing treatment (94640), consisting of Duoneb 2.5 mg albuterol/0.5 mg ipratropium (J7620) ensues, with a peak flow meter (A4614 Peak expiratory flow rate meter, hand held) and nebulizer mask provided.
Continuous positive airway pressure (CPAP), 94660 Continuous positive airway pressure ventilation (CPAP), initiation and management), spirometry (e.g., 94010, 94060, or 94070), and other pulmonary procedures may be conducted with a nebulizing treatment. A handheld or provider-assisted peak expiratory flow meter (A4614), or (depending on the payer) a peak expiratory flow rate study (S8110 Peak expiratory flow rate (physician services)) may be provided.
Other drugs represented by HCPCS Level II codes J7604-J7685, popularly known as Accuneb®, Xopenex®, Proventil®, Brethine®, Azmacort®, and other brands or market labels, may be administered.
If there are comorbid conditions such as laryngitis or pharyngitis, a throat culture (87880 Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A) may be performed at the same session.
Treatment During Non-traditional Hours
When an inhalation treatment is done outside of regular business hours, some payers may allow additional reporting of 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, weekends), in addition to basic service or 99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service for services provided when the office is open during “non-traditional” hours. Check with each payer in your state or locality; some will accept 99050 on a Sunday or holiday, but won’t accept 99051 under any circumstances.
Both the inhalation treatment (94640) and the medication code may be reported in multiple units. Sometimes, an initial treatment fails to provide the desired nebulizing effect and must be repeated. If a treatment is performed twice on the same date, add modifier 76 Repeat procedure or service by same physician or other qualified health care professional (as directed by an instructional note beneath the descriptor for this code) to the second occurrence, so the payer doesn’t think you made a duplication error. Some payers may allow or request 94640 x 2, or other variations of multiple treatments.
Code 94644 Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour, with add-on code 94645 Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour (List separately in addition to code for primary procedure), represents a less common method of inhalation treatment administration.
For example: A 76-year-old man with chronic bronchitis was diagnosed two years ago with COPD. He arrives at the ER with sudden shortness of breath and dizziness. He is admitted to the hospital, and the next day he is administered level 2 care along with continuous aerosol treatment for acute airway obstruction (COPD with acute exacerbation) for one hour and 45 minutes. Coding for the level 2 subsequent care is 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Because the aerosol treatment spanned more than one hour but less than two, report 94644 and 94645 x 1. The diagnosis is 491.21 Obstructive chronic bronchitis with (acute) exacerbation (ICD-10 J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation). The facility will bill for the medication (aerosol) and supply (aerosol mask).
Ken Camilleis, CPC, CPC-I, CMRS, CCS-P, is an educational consultant and PMCC instructor with Superbill Consulting Services, LLC. He is also a professional coder for Signature Healthcare, a health system covering much of southeastern Massachusetts. Camilleis’ primary coding specialty is orthopedics.