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Pulmonology Coding Alert

Same-Session Teaching and Nebulization Can Pay the Bills

Published on Thu Jul 07, 2005

Experts help you ease your inhaler demonstration reimbursement woes

If you find yourself spending too much time losing significant pay for teaching patients how to use their nebulizers, follow our two simple tips to break a bad habit. 

Tip 1: Identify a Distinct Service

Some payers will only reimburse for the 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 not the teaching (94664, Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device), writes Anika Potts, office administrator at Kids First Pediatric Group in Stockbridge, Ga.
 
Try this: You could append modifier 59 (Distinct procedural service) to 94664 when appropriate, says Christina T. Todd, CCS-P, director of medical review and compliance at EHS Inc. in Hunt Valley, Md. "We've had better success getting paid for the separate teaching session since we started reporting 94664-59."

Here's why: When you report same-session nebulizer treatment and training, you may use modifier 59 to designate 94664 as a distinct procedural service from 94640, coding experts say.

Caution: Not all payers require modifier 59 on the nebulizer demonstration code, experts say. But you might have to use the modifier if an insurer includes the training in the treatment.

Why: The National Correct Coding Initiative (NCCI) considers 94664 a component of 94640. Therefore, private payers may adopt the CMS edit and include the demonstration in the training.

Tip 2: Use Modifier 59 for Different Procedure

You can use modifier 59 to unbundle the demonstration (94664) from the treatment (94640). "Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day," states CPT Appendix A - Modifiers.

Remember: Modifier 59 may represent one of the following relationships between the two procedures/services:
 

  • different session or patient encounter
  • different procedure or surgery
  • different site or organ system
  • separate incision/excision
  • separate lesion
  • separate injury.

    Example: An established patient presents in respiratory distress. You evaluate the patient and administer a nebulizer treatment using a unit dose of Albuterol.

    After the patient recovers, you prescribe a new inhaler. A nurse demonstrates proper inhaler technique, has the patient practice using the inhaler and corrects the patient's misuse.

    Solution: You could code the encounter as CPT codes:
     

  • 99212-99215 with modifier 25 to notify carriers that this was a significant, separately identifiable office visit
     
  • 94640 for the nebulizer treatment
     
  • 94664 with modifier 59 to report the distinct procedural training administered by the nurse
     
  • J7613 for the drug administration of 1 unit dose, 1 mg, of Albuterol.

    ICD-9 code: 

  • 493.02 (Extrinsic asthma; with [acute] exacerbation).
     
    E/M: You would report 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to identify the asthma evaluation as significant and separately identifiable from the nebulizer treatment (94640).

    Other services/procedures: Report 94640 for the inhalation treatment and 94664 for the nurse's inhaler demonstration and evaluation since the new prescription required separate demonstration of the new inhaler. Append modifier 59 to 94664 because it is the bundled code.

    Supply: Use the new HCPCS code for a unit dose of Albuterol: J7613 (Albuterol, inhalation solution, administered through DME, unit dose, 1 mg).

    Diagnosis: For the ICD-9 code, you would assign 493.02 (Extrinsic asthma; with [acute] exacerbation). The fifth-digit subclassification of "2" indicates the patient was having an acute exacerbation.

    Red flag: Before you report 94664-59 to an insurance company, make sure it accepts modifier 59.

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