Pediatric Coding Alert

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?


California Subscriber


Answer: Try using a modifier on three codes, rechecking your diagnoses and reordering the codes in order of importance.

First: CPT does not require you to use modifier 25 (Significant, separately identifiable E/M 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 E/M 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 that the service is significant and separately identifiable from the nebulizer treatment.

Next: To distinguish the nebulizer treatment as a distinct procedural service from the strep test (87880, Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A), use modifier 59 (Distinct procedural service) on 94640.

Also: The strep test (87880) is a Clinical Laboratories Improvement Act 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 a diagnosis of 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). Using 465.8 with 87880-QW could cause a denial.

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 to list the diagnosis involving the highest risk first: 519.11 (Acute bronchospasm) linked to the E/M service (99213-25) and the nebulizer treatment (94640-59). You could report as a secondary diagnosis 465.8 with the office visit. The optimal coding would be:

• 99213-25  519.11/465.8

• [...]