Pulmonology Coding Alert

Before you bill Medicare for your next nebulizer treatment dose, you'd better update your codes -- or risk nonpayment.

The first half of 2007 marks a major re-sweep of albuterol and levalbuterol codes. Here are four steps you can't afford to dodge -- and one FAQ that will help your future drug billing.

For Medicare, you can forget the J codes for albuterol and levalbuterol that you just learned two short years ago. CMS is once again changing the HCPCS level-II codes associated with these drugs. Effective July 1, 2007, Medicare Part B carriers no longer pay for J7611-J7614, says Christine Martin, CPC, office manager at Fremont Pulmonary Care in Nebraska.

New way: You should now use a Q code when billing Medicare for inhalation solution that your practice purchases and provides for a 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]) and for pre/post-spirometry (94060, Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration). The new Q codes include:

To avoid Medicare claim denials for codes J7611-J7614, mark the codes in your computer system as "invalid for Medicare as of 07/01/07."

"Don't delete the codes," which private payers may still accept, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City. Designating the codes as invalid for Medicare prevents staff from accidentally assigning the codes to Medicare claims.

Codes for albuterol/levalbuterol that are nonpayable by Medicare include:

Although CMS doesn't swap one inhalation solution J code with one Q code, you can easily wrap your hands around the uneven change. When looking at the new Q codes, Martin recommends thinking:

• Q4093 = J7611 or J7612

• Q4094 = J7613 or J7614.

To read about the HCPCS code changes for albuterol and levalbuterol, see MLN Matters Number: MM5645, posted at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5645.pdf.

Earlier this year, CMS issued a revised policy that denies coverage for compounded inhalation solutions on the basis that they are medically unnecessary. That policy change took effect July 1. Because a compounded inhalation solution is not a Food and Drug Administration- approved product, CMS dropped coverage of all such drugs, according to Noridian (Part B for 17 states).

(Find out more about the policy changes at www.noridianmedicare.com/dme/news/docs/2007/03_mar/policy_changes.html.)

Best bet: Before using a compounded solution -- one that is mixed, combined or altered for an individual -- make sure that the physician cannot effectively provide the treatment with a noncompounded solution. "If not, provide the patient with information (risks of not pursuing treatment, benefit of following through with treatment, and the financial responsibility involved) so that he may make an informed choice to proceed with treatment," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

The patient does not have to sign an advance beneficiary notice (ABN) for services and items that are excluded from coverage. "ABNs are only required for covered services that are deemed 'not medically necessary,' " Pohlig say. "Compounded solutions do not meet this latter description."

Do this: Code compounded versions of J7525 (pentamidine), J7608 (acetylcysteine), J7631 (cromolyn), J7639 (dornase alpha) and Q4080 (iloprost) with J7699, instructs Noridian's coding guidelines for inhalation solutions (www.edssafeguardservices.eds-gov.com/admin/viewdoc.asp?fn=Nebulizers_-_Policy_Article_-_Effective_01-01-2007.pdf). Reserve the specific J codes for the FDA-approved product.

Believing in one common myth can spell disaster for your drug coding. When coders can't locate a J or Q code on the Medicare Physician Fee Schedule, they often think that Medicare doesn't pay for the drug.

Reality: CMS pays drugs using the Average Sales Price (ASP) file, not the Medicare Physician Fee Schedule. You can find a Medicare fee schedule for J codes at www.cms.hhs.gov/McrPartBDrugAvgSales

Price/01a_2007aspfiles.asp#TopOfPage. The July 2007 file lists a payment limit of $0.127 (per mg for albuterol and 0.5 mg for levalbuterol) for Q4093 and $0.525 (per unit dose) for Q4094.

Caution: Do not use a HCPCS level-II code to bill for a drug, such as albuterol, when your practice does not incur a cost (for instance, your patient brings the drug into the practice).

"To reduce practice incurred costs, a physician may write a prescription for a patient to fill at his pharmacy for administration of the medication at the physician practice," Pohlig says. Because the practice has not incurred a cost, the physician should not submit a claim for the drug, she says.