Pulmonary Coding:do's And Don'ts Of Inhaler Service Claims

By Author: Angela Martin
Total Articles: 206
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The three things to remember when reporting for inhaler demo/evaluation are: (1) the type of device used, (2) documentation requirements and (3) qualifying modifiers. The following ‘yes' and ‘No' show you why some payers would deny payment for this service and what you should do to outsmart them.

Yes : Misjudge advair diskus

The Advair Diskus is an "aerosol generator. If the nurse/medical assistant taught someone to use an Advair Diskus -- or any other diskus, you should report 94664.

For instance: A pulmonologist starts a patient with asthma on Advair. A nurse then teaches the patient how to use the Diskus. A nurse then teaches the patient how to use the Diskus. As per CPT guidelines, you should go for 99201-99215 for the office visit and 94664 without a modifier.

That apart, CMS transmittal R954CP also indicates that modifier 25 applies only to E/M services performed with procedures that carry a global fee, which 94664 does not have.

Nevertheless, many payers will only pay for the service if you add modifier 25 to the visit code. It is always best ...
... to check with your major insurers' policy first.

No: Bundle dose in teaching session

The patient may administer medication dose during the teaching session. Both services (treatment + teaching) are bundled into one CPT: 94640, so you shouldn't report them separately.

Here's why: The administration was carried out as part of the demonstration/evaluation.

No: Report separate education minus modifier 59

Suppose that during an outpatient visit, an asthmatic patient is wheezing and having difficulty breathing, which requires one or more bronchodilator treatments for intervention: 493.01, Extrinsic asthma; with status asthmaticus; 493.02, Extrinsic asthma; with (acute) exacerbation; 493.21, Chronic obstructive asthma; with status asthmaticus; or 493.22, Chronic obstructive asthma; with (acute) exacerbation. The patient did not use his MDI device, nebulizer, etc, properly prior to visit; as such he was given an education about the use of these devices after the treatment.

Code it: First, report 94640 (adding modifier 76, Repeat procedure or service by same physician, to separate line items of 94640 for multiple treatments) in addition to the proper E/M code minus a modifier, unless the payer requires modifier 25 with the E/M.

Then report 94664 with modifier 59 (Distinct procedural service) as the patient required additional instruction for his daily maintenance medication. This is different from the medication provided for immediate intervention (94640).

In a nutshell: If the patient needed separate education post receiving an inhalation treatment on the same day, you would bill both services (treatment + education), using modifier 59 to 94664.

Logic: The CCI places a level-one edit on 94640 and 94664. As such, Medicare and payers that follow CCI edits may require modifier 59 on the component code (94664) to indicate that the teaching is a distinct procedural service from the inhalation treatment.

Yes: Prove medical necessity

If payers wouldn't pay your 94664 claim, you would need to support it with documentation indicating medical necessity to reimburse the approximately $14 national rate. For example, you might need to state in the plan or treatment portion of the written record that the patient requires a teaching session on the use of his MDI, diskus, nebulizer, and the like. That apart, do not forget to note why the session is required.

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