Pulmonology Coding Alert

Question: When an established patient with emphysema presents complaining of shortness of breath, what CPT code should I report? The physician provides inhalation treatment, teaches the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision-making of low complexity.Montana SubscriberAnswer: You would need to report more than one CPT code in this case. First, you should use 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]) to cover the all-encompassing service the physician provided. This code also depicts that the physician's main intent was to treat the acute obstruction.The office visit would warrant the code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: [...]