Here are three things you should keep in mind when reporting inhaler demo/evaluation: 1) The type of device used 2) documentation requirements and 3) qualifying modifiers. The following do’s and don’ts tell you why some payers would deny payment for this service and what you should do to outsmart them.
Do not 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 – or any other diskus – you should use 94664.
Do: 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; therefore you should not report them separately.
Here’s why: The administration was carried out as part of the demonstration/evaluation.
Don’t: Report separate education without modifier 59
Let’s take that during an outpatient visit, an asthmatic patient is wheezing and having difficulty breathing, which requires one 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, and the like properly prior to visit, so he was given an education about the use of these devices after the treatment.
Code it: First, code 94640 (adding modifier 76, Repeat procedure or service by same physician, to separate line items of 94640 for multiple treatments) in addition to the right E/M code without a modifier unless the payer needs modifier 25 with the E/M.
Then use 94664 with modifier 59 (Distinct procedural service), as the patient needed additional instruction for his daily maintenance medication. This is different from the medication provided for immediate intervention (94640).
In a nutshell: If the patient required separate education after receiving an inhalation treatment on the same day, you’d bill both services (treatment + education), appending 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 need modifier 59 on the component code (94664) to indicate that the teaching is a distinct procedural service from the inhalation treatment.
Do: Prove medical necessity
If payers wouldn’t pay your 94664 claim, you’d 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 needs a teaching session on the use of his MDI, diskus, nebulizer, etc. To add to it, do not forget to note why the session is required.
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