Pulmonology Coding Alert

Know when to report nebulizer demonstrations with therapy.

Accurately reporting nebulizer inhalation treatments depends on your assessment of all the services that your pulmonologist performed during that session. Apply the guidance that follows to nail down nebulizer session particulars and capture all associated services.

Assess Oximetry, Multiple Treatments

Your pulmonologist may use oximetry and spirometry to evaluate the patient and then decide to manage the patient's symptoms with inhalation treatment using an aerosol generator such as Advair Diskus. You would then use 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]) for the services. Oximetry is bundled into 94640 and should not be reported separately whereas the spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) may be separately reported.

When your pulmonologist provides multiple inhalation treatments during the same session, you need to report each course of treatment separately. "If multiple inhalation treatments are given during the same session, you should code 94640 with a 76 modifier (Repeat procedure or service by same physician or other qualified health care professional)," says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. "Thus for the second (or third) treatment you would code 94640, 94640-76."

Don't Code for Training Sessions as a Norm

When your pulmonologist provides inhalation treatment to the patient, it is often common to see him providing training to the patient on the correct usage of the inhaler or the nebulizer. But you should not report the training separately with 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) in every case of inhalation therapy that your pulmonologist is providing.

You can report 94664 in addition to 94640 if your pulmonologist provided the demonstration separately and not as a part of the administration of the treatment.

"The education associated with 94644 is inherent in 94640," adds Plummer. As code 94664 is a column 2 code for 94640, you will have to append the modifier 59 (Distinct procedural service) to 94664 when reporting both the services together.

Example: An established patient with prior history of asthma reports to your pulmonologist's office with complaints of wheezing. Your pulmonologist, after assessment of the patient's condition, decides to manage the patient's symptoms with inhalation therapy. Once the patient's symptoms of wheezing subside, the patient complains that he was not able to use the metered dose inhaler that he was provided. Your pulmonologist then proceeds to explain the usage of the device to the patient.

In this scenario, you code 94640 for the treatment provided and the instructions provided with 94664-59 as this demonstration was provided after the medication was administered.

Don't Forget to Capture the E/M Services Performed Prior

If your pulmonologist performed an office visit to assess the condition of the patient that resulted in the decision to perform an inhalation therapy, make sure that you are capturing the E/M services with the appropriate code. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other Service) to the E/M code to ensure that you are informing the payer that the service was significant and separately identifiable from the inhalation therapy. Make sure the documentation supports the evaluation and the management code that you are billing.

Example: A patient arrives at your pulmonologist's office with complaints of wheezing and shortness of breath. Your pulmonologist performs a comprehensive evaluation of the patient's previous history and assessment of the patient's symptoms. Based on the observations and a comprehensive examination, your pulmonologist perform an inhalation therapy using a nebulizer for the acute exacerbation of the patient's chronic asthmatic condition.

In this scenario, you report code 99204 (Office or other outpatient visit for the evaluation and management of a new patient...) for the E/M services performed and 94640 for the inhalation therapy with the nebulizer.

Continuous Therapy Calls for Different Code

If your pulmonologist opts for continuous inhalation treatment for a period of sixty minutes or more, you cannot use 94640 to report the treatment procedure. You will have to report this procedure using 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour) for the first hour of treatment. "If the intermittent therapy lasted an hour, you can't code 94644," says Plummer. "You can only code 94644, if continuous (not intermittent) inhalation therapy is given for one hour." Use the code +94645 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour [List separately in addition to code for primary procedure]) for every additional hour of therapy that your pulmonologist provides.

Reminder: The Correct Coding Initiative (CCI) edits indicate that code 94640 is a column 2 code for 94644. So these codes cannot be billed together under any circumstances. Code 94640 is bundled into code 94644 as this is a more extensive procedure.