Break down nebulizer sessions to capture allowable services and procedures.
Nebulizer coding made easy
Although CPT 2003 clarified the nebulizer training codes, how to report nebulizer sessions can still be puzzling. By understanding how to code each service and recognizing that payer policies vary, you can bill these procedures and services with confidence.
You often treat patients for wheezing and difficulty breathing due to asthma, lung disorders, or upper respiratory infections. These office visits can take a lot of time because they encompass many services, including patient history, examination, and medical decision-making, and procedures, such as spirometry and bronchodilation, and training.
Let's look at a typical session when a patient presents at the office for wheezing (786.07). You review the patient's history and examine him, concentrating on the lungs, upper airways, eyes, ears, nose (particularly the nasal passages), and throat.
You can't evaluate the airways from the exam alone, so you get a pulse oximetry reading and use a spirometer to measure pulmonary function. You administer a bronchodilator, then get another pulse oximetry reading and repeat spirometry, comparing the before and after readings to assess the bronchodilator's efficacy.
If the patient continues to exhibit respiratory symptoms, you administer a second bronchodilator followed by spirometry. The pulmonary reading shows that the patient's symptoms are subsiding. You prescribe an inhaler and a spacer, and a nurse demonstrates how to use the inhaler. You and the nurse have performed seven services:
pulse oximetry twice
spirometry before and after bronchodilation
established patient office visit
Coverage for pulse oximetry (94760, noninvasive ear or pulse oximetry for oxygen saturation; single determination) depends on the payer.
Medicare pays separately for 94760 if it's the only procedure provided. This means that if you bill any other code on that day, you can't bill pulse oximetry as wellMedicare has bundled the oximetry codes into every other CPT code.
Carriers equate pulse oximetry to taking a patient's temperature. "Pulse oximetry is no more invasive and arguably less invasive than recording the patient's temperature, another example of a diagnostic service for which we do not make separate payment," according to CMS. "If interpretation of pulse oximetry or temperature data is complex, then that interpretation is clearly part of the medical decision-making included in the E&M services." CMS adds that facility and practice expense payments cover the equipment costs.
Various commercial payers have followed Medicare's lead. Some carriers, however, do not bundle pulse oximetry with other codes, so you can bill for it separately. Because two pulse oximetry determinations were made in this scenario, report 94761 (noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations [e.g., during exercise]), says Kent J. Moore, manager of healthcare financing and delivery systems for the American Academy of Family Physicians in Leawood, KS.
Track commercial payers that bundle pulse oximetry, and write off the charge before it goes out the door. But make sure to keep the code(s) on your Superbill and on the claim form as well.
For the spirometry before and after bronchodilation, report 94060 (bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]). Bronchospasm evaluation describes the evaluation and respiratory function measurement, and thus includes spirometry before and after bronchodilation. Don't bill separately for 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) in this case. Note that 94010 specifies that the spirometer must display results graphically, which also applies to 94060.
Many practices think a peak flow reading that's written in the chart counts as spirometry.
"It does not," says Daniel S. Fick, physician director of risk management and compliance for the Roy J. and Lucille A. Carver College of Medicine faculty practice at the University of Iowa in Iowa City. "You can't bill for a peak flow." Assign 94060 for each before and after reading. If you perform a third spirometry after a second bronchodilation, report 94060 twice.
For each inhalation treatment, report 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]).
Some doctors mistakenly include additional services, such as spirometry and training, in 94640. The AMA's April 2000 CPT Assistant clearly states, "94640 is reported for inhalation treatment for an acute airway obstruction, such as asthma or croup, and can represent an aerosol or nebulized administration of the appropriate medication, as prescribed by the physician."
Spirometry and inhalation treatment are different procedures performed for different reasons. Report both the diagnostic and the therapeutic procedures, says Susan Callaway, an independent coding auditor and trainer in North Augusta, SC, but you may run into problems in doing so. The National Correct Coding Initiative (NCCI) bundles 94640 into 94060. Medicare interprets 94060's definition of pre- and postbronchodilation as a global code, meaning the bronchospasm evaluation includes the inhalation treatment. For payers that follow Medicare's lead and NCCI edits, you can't report 94640 with 94060. So if you perform both, bill 94060, which has a higher relative work value.
"Bundling issues are payer-specific," Callaway says. So don't stop reporting the treatment until you review your carriers' policies. Submit claims with both procedures, and when you receive the explanation of benefits, note the insurers' payments and track their preferences so you can tell which rules they follow.
If a payer includes the inhalation treatment in the bronchospasm evaluation, remember that you can still report these procedures if you do them at different sessions.
For instance, a child returns to the office later the same day because he can't use the at-home treatment and has an acute exacerbation. You then do a nebulizer treatment, and report 94640 for the inhalation treatment appended with modifier 59 (distinct procedural service) to indicate a separate session from the spirometry that you performed earlier.
Although the carrier may bundle 94060 and 94640 when you perform them together, you can still report them when you do them at separate sessions.
Practices report varying success when coding multiple treatments. But according to CPT 2003, "For more than one inhalation treatment performed on the same date, append modifier 76 (repeat procedure by same physician)."
Some carriers may prefer you to bill nebulizer treatments per unit. To complicate issues, some coding experts suggest using modifier 51 (multiple procedures) for payment of multiple nebulizer treatments. Remember, modifier 51 will reduce reimbursement for the second procedure by 50 percent based on standard multiple-procedure rules.
CPT 2003's directive may help payers recognize modifier 76, but you should still follow individual carriers' guidelines.
Based on these recommendations for the two inhalation treatments, you could report one of three options, based on the payer:
94640 twice (some carriers allow billing for multiple aerosol treatments without a modifier).
Or, if the carrier follows NCCI, you may report 94060 only, and not 94640. Some practices cite success in appending modifier 59 to all procedures (9476059 twice, 9406059, 9401059, 9464059 twice).
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Coding Consult: Nebulizer coding made easy. Medical Economics Nov. 7, 2003;80:22.