Pulmonology Coding Alert

Follow these steps to stay on the right side of the auditors’ gaze.

It’s never a pleasant notification when you hear that a RAC review is coming your way, but that may be a reality for scores of pulmonology practices in the near future. RACs have made nebulizers an audit focus effective within the last few months, and if your claims are found to be in violation, you could be facing paybacks.

Background: Recovery audit contractors (RACs) review Medicare claims for errors and collect a contingency fee based on the amount they recover. Much like MACs, there are different RAC contractors for the various regions in the country, and each one publishes the open issues that it is in the process of auditing.

One such issue on the plate for 2017 with multiple RAC regions involves nebulizers. Region five (RAC contractor Performant Recovery) recently announced that it will be reviewing the following issues involving nebulizers:

• Medical Necessity and Complex Coding Nebulizer: “Documentation will be reviewed to determine if the nebulizers, compressors, related drugs, and accessories meet Medicare coverage criteria, meet applicable coding guidelines, a validation of the drug dosage administered versus dosage billed, and/or are medically reasonable and necessary,” Performant said in its detail page for this audit issue, which was approved on April 14.
• Automated Nebulizers Not in Accordance with Billing Requirements: “Overpayments were identified where diagnosis codes were not in accordance with billing requirements outlines in local coverage determinations (LCDs) for nebulizers, related drugs, and accessories,” Performant noted when it launched this audit issue on Feb. 2.

Know the Right Way to Code These Services

Since it’s clear that auditors are homing in on nebulizer claims, now is a good time to brush up on how to report these services.

Take this example: During an office visit, the physician decides to initiate nebulizer treatment due to the patient’s worsening breathing problems. In such a case, you should submit the appropriate evaluation and management (E/M) office visit code (99201-99215), and the CPT^® code for the nebulizer treatment 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device).

Append Modifier 25:  Because the Correct Coding Initiative (CCI) bundles most of the office-based E/M codes into 94640, you should 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 E/M code when you’re reporting these services together.

Diagnosis coding: You can support the treatment with ICD-10 diagnosis codes such as J45.21 (Mild intermittent asthma with [acute] exacerbation) or J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation) in most cases. However, ensure that you’ve listed the most accurate ICD-10 code on your claim based on the documentation, and not selected because of which codes are listed as allowable on the LCD.

Code 94640 is mostly used in office settings where the treatment is less than an hour. For prolonged inhalation treatment scenarios, you should opt for 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour) and +94645 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour [List separately in addition to code for primary procedure]).

Avoid 94640 for Training

If the pulmonologist is performing a demonstration of how to use a nebulizer, you shouldn’t report 94640. Instead, you’ll bill 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) in these situations. Although 94640 only pays about $1.00 more than 94664 (and thus, you may think of the codes as interchangeable), you must code correctly no matter what. Insurers are looking for other issues besides overpayments when they launch audit reviews, so it’s important to select the right code no matter what.

“It is important for the physician’s order and the administration documentation to identify the name and dosage of the drug being used for the inhalation treatment,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. “Since there are many different inhalation agents to select, the auditor will be looking to confirm whether the drug used is a combination of agents, compounded or non-compounded, and the dosage.”

Resource: To read the audit issue detail on the RAC page, visit https://www.dcsrac.com/IssuesUnderReview.aspx.