Pulmonology Coding Alert

Question: During an outpatient visit, an asthmatic patient was wheezing and having difficulty breathing. Our pulmonologist started the patient with metered dose inhalers. The patient was given a training session for demonstrating the proper use of the inhaler along with an initial dose. How should I code the encounter? Our office had recently faced rejection for 94664 for reimbursement for training time? Can I challenge this?

New York Subscriber

Answer: According to your description, you provided both the medication dose and education during the same teaching session. Therefore, you should use a bundled CPT® code for both services (treatment + teaching) 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]). The reason is that the administration was performed as part of the demonstration/evaluation. As per CPT® guidelines, you can also report an appropriate E/M code from among 99201-99215 for the office visit, depending upon the time spent and the complexity of the encounter. You may add modifier 76 (Repeat procedure or service by same physician) to separate line items of 94640 for multiple treatments.

Note: Some carriers may require a modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) with the E/M, so make sure with your carrier about the individual rules.

For the denial of 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device), you can challenge training denials, provided your documentation supports the education’s reason. However, all payers may not pay for the approximately $17.19 for the code 94664. Please check that you have fulfilled the condition that you have used code 94664 as a standalone procedure code. Insurers consider 94664 a component of 94640. So, if you report 94640, you cannot separately report 94664 and expect payment if the provider performed the two procedures on the same patient and on the same day

When it is appropriate to report both services, you may have to add modifier 59 (Distinct procedural service) to 94664.

You also need to support the claim with documentation indicating medical necessity to reimburse the session. For instance, you will need to state that the treatment provided to the patient was delivered via nebulizer (along with details of the treatment), and document in the patient’s Assessment/Plan that the physician is newly prescribing a MDI, which requires a teaching session on the use of his new MDI (with session details).