Coding Strategy

Focus on form and drug to pinpoint the correct asthma supply code.

Are you clear on how to report asthma procedures and inhalers? Follow this advice, and you’ll breathe easy when it comes to asthma related claims.

Propellant-Driven Inhaler Falls Under 94664

If there’s confusion in your office over whether to use 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler, or IPPB device) to report education/training with the Advair diskus, look no further for your answer.

Code 94664s descriptor specifies demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device. Part of teaching the proper technique in using an inhaler (either propellant-driven [Advair Diskus] or dry powder) is to demonstrate and evaluate. In this respect, the code would seem appropriate to use for demonstration and evaluation, say sources with the Joint Council of Allergy, Asthma & Immunology.

The drawback: Not all payers will reimburse 94664. If practices abuse 94664, probably fewer payers will pay. To support reporting 94664, documentation should include an indication of medical necessity.

Clear Up Inhaler Code Confusion

Patients sometimes need multiple nebulizer treatments in the office to control acute asthma. If you’ve wondered whether to bill 94640 and J7613 multiple times, one time, or one time with modifiers for additional treatments, follow this advice and youll breathe easier.

Submit 94640 for Each Treatment

When a patient receives multiple aerosol treatments on the same date, 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]) for the first treatment.

Subsequent treatments will require modifier 76 (Repeat procedure by same physician), CPT says. Therefore, you would code three nebulizer treatments as:

• 94640 — First treatment
• 94640-76 x 2 — Two subsequent treatments.

A dose of coding: For the inhalation solution, report three units of J7613 (Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg). Because J7613 represents one unit dose, you should report per nebulizer treatment or, in our example, J7613 x 3.

E/M Might Also Be Acceptable

If the allergist meets the criteria, you should report the appropriate-level E/M code (such as 99214, Office or other outpatient visit for the evaluation and management of an established patient …).

If the physician performs and documents a significant, separate E/M from the treatment (94640), append the E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Time is a factor: If the asthma treatment lasted at least an hour, you’d code it with 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour). Report code 94640 for intermittent or one-time treatments.

Clue In to 5th Digit for Asthma Diagnosis

When you submit an asthma diagnosis, don’t forget that ICD-9 requires you to use a fifth-digit sub-classification with asthma codes (493.xx, Asthma). If you submit four digits for an asthma diagnosis, payers will probably reject the ICD-9 code as incomplete.

Correct method: Assign the fourth digit based on the asthma category:

• 493.0x, Extrinsic asthma
• 493.1x, Intrinsic asthma
• 493.2x, Chronic obstructive asthma
• 493.8x, Other forms of asthma
• 493.9x, Asthma, unspecified.

Then, identify the asthmas current state with the appropriate fifth digit:

• 0, unspecified
• 1, with status asthmaticus
• 2, with (acute) exacerbation.

For patients who do not have status asthmaticus or acute exacerbation, use a fifth digit of 0. Code 493.x0 is appropriate when the patients asthma is controlled. A final digit of 1 indicates that the patient has status asthmaticus, which is a medical emergency and is usually treated in the emergency department. You should assign a 2 when something has caused the condition to flare up.

Why it matters: Without this level of specificity, the payer may deny your claim for lack of medical necessity.

Example: An extrinsic asthma patient has an acute exacerbation that requires a nebulizer treatment (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]). In this case, you should link 94640 to 493.02. Reporting a 2 as the fifth digit helps the payer understand why the patient needs the treatment. Without the final digit (or a fifth-digit of 0), the payer may assume that the patients asthma is under control, making the coded treatment unnecessary.

Reinstate Old J Codes to Get Claims Paid

If you flagged J7611-J7614 as invalid for CMS, you can green light the codes with a valid as of April 1, 2008, notation.

The spring-quarter updates to HCPCS 2008 deleted albuterol/levalbuterol codes J7602 (Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 1 mg [albuterol] or per 0.5 mg [levalbuterol]) and J7603 (& unit dose …). HCPCS reinstated:

• J7611 — Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 1 mg
• J7612 — Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 0.5 mg
• J7613 — Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 1 mg
• J7614 — Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 0.5 mg.

The CMS fee schedule Web site recognizes J7611-J7614 and not J7602-J7603.

Switch Back to Drug-Specific Codes

You may recall that CMS once replaced J7611-J7614 with Q4093 (Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 1 mg [albuterol] or per 0.5 mg [levalbuterol]) and Q4094 (& unit dose …)

Both Q4093 and Q4094 were deleted effective Jan. 1, 2008, however. HCPCS introduced new albuterol-levalbuterol combination codes J7602-J7603 to take the place of those deleted Q codes for 2008.
Medicare decided it was better to use the four codes that separated albuterol from levalbuterol, rather than the combined drug codes J7602-J7603.

Focus on 2 J7611-J7614 Factors

You can get the correct noncompounded solution supply code if you zoom in on two items:

• Form- concentrated (J7611, J7612) or unit dose (J7613, J7614).
• Drug- albuterol (J7611, J7613) or levalbuterol (J7612, J7614).

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You may need to append modifier 25, depending on payer policies.

Question: Our physician billed 90634, 90710, and 90606 for vaccines given to a 5-year-old patient. The insurance company denied payment and said they required a modifier. What should we have done differently?

New Hampshire Subscriber

Answer: According to standard CPT coding, vaccine codes do not require modifiers on the associated E/M code. However, you might need to include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) if your insurance company requires it — which might be why you received a denial.

Well check: If your physician administered vaccines on the same day as a well visit, code the well visit with the appropriate code such as …

… 99393 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood [age 5 through 11 years]). You might need to append modifier 25 if vaccinations are given, depending on the payer’s guidelines.

Sick visit: If the child visits because of another problem and receives immunizations during the visit, report the vaccines with the appropriate office visit code from 99212-99214 (Office or other outpatient visit for the evaluation and management of an established patient …).

Then report the vaccine codes: 90634 (Hepatitis A vaccine, pediatric/adolescent doage-3 dose schedule, for intramuscular use), 90696 (Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated -D-TaP-IPV], when administered to children 4 through 6 years of age, for intramuscular use), and 90710 (Measles, mumps, rubella, and varicella vaccine [MMRV], live, for subcutaneous use).

@ Pediatric Coding Alert

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Understand ‘significant’ and ‘separate’ to earn a gold star.

Knowing when to report modifiers and choosing the best one for each situation can be an easy trip-up for coders. If you find yourself especially befuddled by modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), keep reading for real-world tips that will help you code confidently every time.

Starting point: Remember you can only consider reporting modifier 25 when coding an E/M service. If the procedures you’re reporting don’t fall under E/M services, check whether the encounter qualifies for modifier 59 (Distinct procedural service) instead.

1. Verify That Service Is Significant

As CPT’s Appendix A explains, a significant and separately identifiable service “is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.” Ask yourself two questions when deciding if your case meets the criteria:

• Could the complaint or problem stand alone as a billable service? A single trigger point injection (20552, Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]), for example, qualifies as a stand-alone service you might see in conjunction with an E/M visit.
• Do you have a different diagnosis for the portion of the visit unrelated to the initial service? For example, the patient might be in the office for a planned knee injection, but also complains of shoulder pain during the visit.

Reporting an E/M code with modifier 25 would be appropriate for the services performed and documented concerning the shoulder.

If you can answer “yes” to either question, you’re one step closer to reporting modifier 25.

Example: “My physicians complete a lot of lumbar and cervical injections that have a 0-day global period,” says Mary Baierl, RHIT, CPC, CCA, CMT, a coder with BayCare Clinic, Pain Management and Rehabilitation Medicine in Green Bay, Wis. “When they evaluate the patient in the office, offer an injection, and have time to do the injection that day, we code the injection and include office visit E/M code with modifier 25 as a separately identifiable service.”

2. Check for Additional Work

If the diagnosis remains the same, Quita Edwards, CCS-P, CPC, COSC, CPC-I, owner of CASE Contracting Services in Fort Valley, Ga., says you have a third question to ask: Did your orthopedist perform extra work that went above and beyond the typical pre- or postoperative work associated with the procedure code? Another affirmative answer points you to modifier 25.

Example: A patient comes to your office for a scheduled joint injection. She has received injections to treat knee pain due to osteoarthritis but they don’t provide long-term relief. During the appointment your physician says she needs to begin thinking about surgical intervention. He spends between 30 and 40 minutes discussing the risks and benefits of surgery so the patient can make an informed decision.

Even though the diagnosis you report for the injection and the E/M service will be the same, you can separately report the two services in this case. “The physician spent enough time discussing the surgery to count as significant and separately identifiable from the injection,” Edwards explains. “You can bill an E/M code with modifier 25 based on the amount of time he spent, even though he didn’t evaluate the patient.”

3. Look for Pre-Planning

Modifier 25 is meant for those “oh, by the way” type situations, not procedures that are tied to previous services. Consider these scenarios and whether you think they merit modifier 25, then watch the Medical Coding News for our experts’ recommendations.

Scenario 1: Your orthopedist sees Mrs. Jones in the office and gives her a prescription for pain medication to help her wrist pain. He says that if this doesn’t help, he’ll give her a wrist injection when she returns. Mrs. Jones returns to the office two weeks later for the injection. Your physician completes another evaluation prior to administering the injection.

Scenario 2: Your physician treats Mrs. Adams for a minor shoulder injury. She returns a few days later because her arm was snatched during activity and she’s experiencing significant pain. The physician completes a full evaluation before prescribing treatment.

Scenario 3: Your surgeon completes total hip arthroplasty on Mr. Brown. Six weeks after the surgery, Mr. Brown returns to your office and sees a different physician because of an ankle sprain.

@ Orthopedic Coding Alert

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Check out this week’s free webinar on the HPI elements of E/M coding. Join the Supercoder Facebook Fanpage for more details.

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Don’t forget to include the code for the arthrocentesis.

Question: A new patient sees the orthopedist because of shoulder problems. The physician schedules an MRI and the patient returns the following week to discuss the findings. The physician had already reviewed the films and goes over them in depth with the patient. He also administered a shoulder joint injection to help relieve the patient’s pain.

What diagnosis should we report with the E/M service to reflect the amount of time spent reviewing films and counseling the patient and to distinguish it from the injection?

West Virginia Subscriber

Answer: Select a diagnosis based on your provider’s documentation, such as rotator cuff tear (840.4, Sprains and strains of shoulder and upper arm; rotator cuff [capsule], or 727.61, Rupture of tendon, nontraumatic; complete rupture of rotator cuff). Include that diagnosis with …

… the appropriate E/M code for your physician’s service (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …). Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Also report 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) with 719.41 (Pain in joint; shoulder region) for the shoulder injection.

@ Orthopedic Coding Alert

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Want to know more about orthopedic coding? Attend the 2010 Orthopedic Coding Update training event and the Shoulder Surgery Coding Secrets You Need to Know audio conference.

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Reading 44373’s code descriptor is key to getting your G Tube claim right.

Question: The gastroenterologist goes to the hospital to treat a patient that had recently been admitted because his gastrojejunostomy tube had migrated to his stomach. After performing a problem focused interval history and exam, the gastroenterologist decides to perform an EGD to reposition the tube. I cannot find a code for repositioning a G tube; how should I code this scenario?

Answer: Judging by your encounter description, the patient’s percutaneous jejunostomy tube (J tube) slipped and became a percutaneous gastrostomy tube (G tube). On the claim, report the following:

• 44373 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneousgastrostomy tube to a percutaneous jejunostomy tube) for the EGD;
• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity …) for the E/M;
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99231 to show that the E/M and tube fix were separate services; and
• 536.42 (Disorders of function of stomach; gastrostomy complications; mechanical complication of gastrostomy) appended to 44373 and 99231 to represent the patient’s condition.

Explanation: The descriptor for 44373 might be a bit misleading, but it mentions only “tube conversion.” The tube does not necessarily have to be new.

@ Gastroenterology Coding Alert

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