A newly issued federal regulation, if allowed to stand, would limit women’s access to care and force doctors to withhold information about all of their health care options. The AMA says…
When reporting inhaler service, you should remember the type of device the provider is using, but shouldn’t stop with just that. Documentation requirements and qualifying modifiers are just as important when coding for inhaler services.
When you’re confused why some payers would deny reimbursement for certain inhaler claims, the following ideas could guide you to a better understanding of how inhaler service codes work out.
94664 Is Your Ticket to Diskus Demo Pay
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 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).
For example, a pulmonologist starts a patient with asthma (493.00, Extrinsic asthma; unspecified or 493.20, Chronic obstructive asthma; unspecified) on Advair. A nurse then teaches the patient how to use the Diskus. As per CPT guidelines, you should report 99201-99215 for the office visit and 94664 without a modifier, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.
In addition, CMS transmittal R954CP also indicates that modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) applies only to E/M services performed with procedures that carry a global fee, which 94664 does not have.
Nonetheless, many payers will only pay for the service if you append modifier 25 to the visit code. It’s always best to check with your major insurers’ policy first.
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 (Pressurized or nonpressurized inhalation treatment for acute...
Often a nurse or medical assistant helps a patient with an inhaler demo or evaluation, but whenever coding it, you must keep these three areas in mind: the type of device used, documentation requirements, and qualifying modifiers. Follow these four tips from our experts to understand why some payers might deny payment for the service — and what you can do to win deserved dollars.
1. Categorize the Diskus Correctly
Many physician offices use the Advair Diskus for their patients, which is an aerosol generator. “An aerosol generator is a device that produces airborne suspensions of small particles for inhalation therapy,” explains Peter Koukounas, owner of Hippocratic Solutions medical billing service in Fairfield, N.J. If the nurse or medical assistant taught someone to use an Advair Diskus — or any other diskus — you should report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).
The physician starts a patient with asthma (493.00, Extrinsic asthma; unspecified or 493.20, Chronic obstructive asthma; unspecified) on Advair. A nurse then teaches the patient how to use the Diskus. According to CPT guidelines, you should report 99201-99215 for the office visit (depending on whether you’re treating a new or established patient). Then report 94664, but don’t append a modifier, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.
CMS transmittal R954CP indicates that modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) applies only to E/M services performed with procedures that have a global fee period. Code 94664 does not have a global fee period, which is why you don’t automatically include modifier 25.
Despite what CMS guidelines might...
If patient’s critical care and visit satisfies time regs, 99291 is the better bet.
When scouring the notes for evidence of an emergency department caveat scenario, coders can easily forget to ask themselves one simple question: Can I report a critical care code for this scenario?
The answer’s yes more often than you might think, says Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La.
“Many patients who qualify for the caveat may also be candidates for critical care. If the condition is severe enough that the patient’s ability to provide this information is impaired, then the condition may be critical,” she explains.
Critical Care Omits Specific History Component
Considering critical care and the caveat simultaneously can make your head spin, as the ED caveat does not even apply to 99291 (Critical care, evaluation and management of the critical ill or critically injured patient; first 30-74 minutes) or +99292 (… each additional 30 minutes [List separately in addition to code for primary service]).
Why? “There are not the same bullet-counting requirements for documentation of history, physical examination, or MDM [medical decision making] for critical care,” explains Edelberg. The descriptors for critical care concern only E/M of the critically ill or injured patient.
So when your physician invokes the emergency department caveat for a patient, check to see if the patient was critically ill or injured; if she was, and the physician documents at least 30 minutes of critical care, consider 99291.
Payout: The only level of service you can invoke the emergency department caveat on is 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a...
Beware: CPT, CMS differ on ‘family discussion’ parameters. When the physician treats a patient with a critical illness or injury, you need to know when to start and stop the critical care clock in order to avoid miscoding. Check out this FAQ to find out what’s part of critical care, what’s not, and how to correctly [...] Related articles: