Easy Guidelines - Profit $16 from 94664

Published: 30th March 2011
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One thing you should remember while reporting for inhaler demo/ evaluation is the type of service the provider is using; however do not stop with just that. When coding for inhaler services, documentation requirements and qualifying modifiers are just as important.

When you are confused why some payers would deny reimbursement for some inhaler claims, here are some ideas that could guide you to a better understanding of how inhaler service codes work out.

Your ticket to diskus demo pay: 94664

If the nurse or medical assistant taught someone to use an Advair Diskus (Advair Diskus is an "aerosol generator) -- or any other diskus, you should code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

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; as such you should not report them separately.

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

Separate education? End it with modifier 59

During an outpatient visit, an asthmatic patient is wheezing and having breathing problems; this requires one or more bronchodilator treatments for intervention: 493.01; 493.02; 493.21, or 493.22. Prior to the visit, the patient did not use his MDI device, nebulizer and the like properly; therefore after the treatment, he was given an education about the use of these devices.

Report it: First, report 94640 (adding modifier 76, Repeat procedure or service by same physician, to separate line items of 94640 for multiple treatments) apart from the proper E/M code minus a modifier, unless the payer needs modifier 25 with the E/M. Then code 94664 with modifier 59 (Distinct procedural service), as the patient required additional instruction for his daily maintenance medication.

This is dissimilar from the medication provided for immediate intervention 94640.

To put it briefly: If the patient required separate education after receiving an inhalation treatment on the same day, you'd bill both services (treatment plus education) adding modifier 59 to 94664.

Logic: The CCI places a level one edit on 94640 as well as 94664. Therefore, Medicare and payers that follow CCI edits may need modifier 59 on the component code (94664) to indicate that the teaching is a distinct procedure service from the inhalation treatment. It's important that the teaching was not part of the treatment for the patient, which would be one parallel encounter teaching while treating.

Easy $16 with the aid of medical necessity support

If payers wouldn't pay your 94664 claim, you would need to support it with documentation indicating medical necessity to reimburse about $16 national rate (0.47 RVUs multiplied by 2011 conversion factor of 33.9764). For example, in the plan of treatment portion of the written record you might need to state that the patient needs a teaching session on the use of his MDI, diskus, nebulizer, and the like. What's more, do not forget to note why the session is required.

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