Pulmonology Coding Alert

Question: Our physician administered drug inhalation (Albuterol in unit dose). How do we report it? Can we get reimbursed for durable medical equipment (e.g., A4627, Spacer, bag, or reservoir, with or without mask, for use with metered dose inhaler) that we use in our physician’s office? 

New York Subscriber

Answer: You can get reimbursed for drugs that represent and incur expenses to the physician. For example, a patient comes in with an acute exacerbation of asthma (493.92, Asthma, unspecified with [acute] exacerbation). The physician administers a bronchodilator via nebulizer (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]).

If the physician administered noncompounded (ready-made) albuterol dosages directly to the patient, you can report the most appropriate Albuterol code, J7611 (Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 1 mg) or J7613 (Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 1 mg) depending upon the concentration form of  the dose.

For administering compounded medication (dosage mixed from individual ingredients by a pharmacist in order to tailor it to a patient’s needs), you can report either J7609 (Albuterol, inhalation solution, compounded product, administered through DME, unit dose, 1 mg) or J7610 (Albuterol, inhalation solution, compounded product, administered through DME, concentrated form, 1 mg).

Whenever a patient picks up a prescription and brings his own medication to your office for the staff to administer, the physician cannot be reimbursed for the medication administration because the physician did not incur the cost of the drug.

Durable medical equipment (DME) represents a different challenge for reimbursement because carriers reimburse only the patient for any expenses personally incurred for DME. To qualify as DME, the equipment must be able to withstand repeated use, be primarily and customarily used to serve a medical purpose, generally not be useful to a person in the absence of an illness or injury, and be appropriate for use in the home. A spacer (A4627) qualifies as DME, and only a patient can report it for reimbursement if a cost was incurred.  This does not guarantee coverage.