Pulmonology Coding Alert

Sorting out which codes to apply to specific respiratory treatments and inhalation therapies can be a challenge, because several different codes relate to these procedures. Recognizing the subtle differences between them is vital to reimbursement. For example, if your pulmonology practice routinely codes 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) for bronchodilator treatment of a patient experiencing an acute bronchospasm, youre coding it incorrectly.

The correct code is 94640 (nonpressurized inhalation treatment for acute airway obstruction), says Walter J. ODonohue Jr., MD, FCCP, FACP, a representative to the AMA CPT Advisory Committee for the American College of Chest Physicians (ACCP), and chief of the pulmonary and critical care division of the Creighton University School of Medicine in Omaha, Neb. This covers aerosol or nebulized administration of medication prescribed for blocked airways, such as in asthma or croup patients. So common is the bronchodilator coding mistake that it was the subject of AMA comment in the April 2000 issue of CPT Assistant , notes ODonohue, who co-authored the article. Despite the explanation offered by the AMA, confusion over the inhalation treatment and therapy codes still persists.

Recognize 94640, 94664-94665 Differences

The primary difference between 94640, 94664 and its companion code 94665 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; subsequent) is that 94640 is for treatment, and 94664/5 are for instructing patients, evaluating their technique in using the bronchodilator, and assessing effectiveness, ODonohue explains.

Codes 94664-94665 describe the following services:

Demonstrating or instructing the patient in the use of a metered-dose nebulizer or inhaler;

Bronchodilation for long-term management of bronchospasm;

Bronchodilation to move thick secretions for therapeutic purposes;

Bronchodilation to move thick secretions so the patient can produce a sputum specimen; and

Diagnostic studies, such as for culture or a gram stain test.

Also, 94664 can be used only once in the patients lifetime with a particular physician, ODonohue says. For example, if a patient has been instructed in the use of a bronchodilator, and the doctor later reinstructs the patient, the appropriate code would be 94665. If the patient changes physicians, and the new doctor demonstrates how to use the bronchodilator, he or she should report 94664.

Note: The single-use intent of 94664 has been questioned recently by pulmonology practices, and the AMA is seeking to apply it to a new, disk-shaped bronchodilator that delivers two types of medications at once. ODonohue recommends coders try submitting 94664 for reimbursement. It would seem justified to use it for instructing a patient in this new type of bronchodilator, because it is an entirely different type of device, and a new technique needs to be explained to patients. However, there is no determination from the AMA yet.

Misreading the description of 94664 contributes to the confusion between it and 94640. People fail to read the initial demonstration and/or evaluation part of the [94664] code. They read aerosol vapor inhalation for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes. Many coders say thats fine because every time they give an aerosol or bronchodilator treatment, theyre mobilizing sputum. This is incorrect. They are overlooking the part of the definition that says, initial demonstration and/or evaluation, and that is the key, ODonohue explains.

Use of Modifier With 94640

Although 94664 can be reported only once, 94640 can be reported multiple times for bronchodilator treatment of acute bronchospasm episodes, even during a single visit. ODonohue offers the following example: A patient is having an acute asthma attack and is given a broncho-dilator treatment, and the condition improves. Another treatment is given and further improvement occurs. A third one is administered. You can bill for each using 94640, modifier -76, (repeat procedure by same physician), and three units of service. But, if you use 94664, you cant bill it ever again for the instruction or evaluation of whether its effective. In this example, the proper way
to code is:

94640;
94640-76 and
94640-76.

However, some non-Medicare insurers may not recognize the modifier, and you should check with your carrier to determine whether documentation should be submitted with the claim. If payment is denied, you should appeal and submit the procedure notes to the insurer, showing how many times the treatment was performed and why. Any other supporting documentation, such as handwritten or dictated notes, should also be included.

Acute Versus Nonacute

Another unique feature of 94640 is that it focuses on treatment of an acute problem, namely, airway obstruction. Code 94664 focuses on the movement of sputum for diagnostic or nonacute purposes, says Mary Mulholland, RN, BSN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvanias department of medicine in Philadelphia. For example, 94664 would be reported when the inhalation of aerosols or other vaporizing medications as prescribed by the physician is required to assist in the mobilization of sputum. The use of the aerosol assists in the opening up of the bronchi, resulting in the mobilization of sputum. This code is reported when the patient cannot produce a sputum specimen without the inhalation of the appropriate aerosol, she says.

However, ODonohue notes, if the patient has an acute airway obstruction caused by secretions, and a nebulizer is used to move them, the service could be coded with 94640. The code doesnt specifically say treatment only with a bronchodilator, he explains.

Coding for IPPB Treatments

Like 94664, another inhalation therapy code designed for one-time use is 94650 (intermittent positive pressure breathing [IPPB] treatment, air or oxygen, with or without nebulized medication; initial demonstration). IPPB treatments use an intermittent positive-pressure cycle ventilator device to deliver pressurized breaths to a patient who is breathing spontaneously, Mulholland explains. The treatment usually lasts 15-20 minutes, and can be indicated for patients exhibiting an impaired or ineffective cough, and can help deliver aerosolized medications to those unable to take deep breaths. Code 94650 is used for instructing the patient (the first time) on how to use the IPPB and equipment, or for evaluation of effectiveness. If the IPPB treatment is repeated, the patient is subsequently instructed, or the physician observes the effectiveness (for the second time), the proper code would be 94651 (... subsequent).

Note: IPPB treatment in a newborn patient is coded with 94652 (... newborn infants).