Pediatric Coding Alert

The next time your practice drops everything to treat an unscheduled patient for wheezing, don't join the screaming children in the waiting room. Instead, take a deep breath with the confidence that you know the ins and outs of billing for the training and the office visit. When treating a wheezing (786.07) patient, a pediatrician can spend hours performing procedures such as pulse oximetry, spirometry, inhalation treatments and training and services including patient history, examination and medical decision-making. If you fail to code for the training and all E/M services, your practice will sacrifice reimbursement to which it's entitled. On the other hand, coding CPT 99214 or 99215 (Office visit for an established patient) inappropriately could raise red flags and result in charges of fraud. (For pulse oximetry, spirometry and bronchodilation, see January's Pediatric Coding Alert.) Code a Typical Scenario The pediatrician and nurse perform seven procedures: pulse oximetry x 2 spirometry before and after bronchodilation spirometry bronchodilation x 2 training And two services: an established patient office visit an emergency service. Note: For a detailed description of this session, see January's Pediatric Coding Alert, page 1. Treatment Does Not Include Training Many pediatricians question whether the 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]) includes training on the inhaler. Code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) is not a treatment, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "It is an instruction session so the patient can perform this service himself."

Much of this confusion stems from the earlier definitions of 94664 (Aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) and 94665 ( subsequent) clarified in CPT 2003. The helpful language eliminates the term "initial" and adds "patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device." In addition, CPT eliminated 94665. These changes clarify that 94664 refers to an inhaler demonstration. "Code 94664 does not include the services described by code 94640," states CPTAssistant, April 2000. Report 94664 for Physician-Supervised Training For the nurse training, you should report 94664. The 2003 National Physician Fee Schedule Relative Value File requires direct physician supervision for 94664. If the office staff demonstrate how to use the nebulizer under direct supervision, use 94664 rather than 99211 (Established patient office visit ...) says Victoria S. Jackson, chief executive officer of Southern Orange County Pediatric Associates and owner of Omni Management, which provides practice management [...]