Basic Guidelines for Inhalation Treatment Billing

There are many services and products that may be billed when a patient presents with chronic asthma or other serious respiratory conditions or acute exacerbation of related symptoms. Physicians must capture all pertinent information in their documentation and, in turn, coders (or those who validate pre-coded electronic health record charges) must account for all related services, medications, and supplies. In ICD-10-CM, a primary code from chapter 10 (Diseases of the Respiratory System) is indicated. Some respiratory or pulmonary conditions may qualify for inhalation (aerosol generator, nebulizer, metered-dose inhaler, or intermittent positive pressure breathing) treatment coding, such as:

  • Asthma; unspecified with status asthmaticus
  • Acute bronchitis
  • Other chronic obstructive pulmonary disease
  • COPD with (acute) exacerbation
  • COPD with an acute lower respiratory infection
  • Pneumonia
  • Bronchopneumonia
  • Acute bronchospasm
  • Cough
  • Wheezing
  • Shortness of breath

Procedures, Services, and Supplies

Although reimbursement for the following items is based on specific payer guidelines (not all payers will reimburse for all services), failure to account for any of these services and products, when covered, will result in lost revenue.

  • Office visit (99201-99215) ‒ The patient is examined to achieve a diagnosis and to conduct or prescribe a treatment plan. The doctor needs to listen to lung sounds and observe a variety of findings. When the provider performs other, separately coded procedures or services during the same encounter, you must append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other services to the visit code. If the patient is scheduled solely for inhalation treatment, no office visit is reported.
  • Inhalation treatment (94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (eg, with an aerosol generator, nebulizer, metered-dose inhaler, or intermittent positive pressure breathing [IPPB] device)) ‒ This is the component of treatment that potentially improves the patient’s condition, or even eliminates ongoing symptoms.
  • Oxygen saturation (O2Sat) (94760 Noninvasive ears or pulse oximetry for oxygen saturation; single determination) ‒ An O2Sat is routinely performed as a preliminary step to assess a patient’s condition. Even a persistent cough with no definitive diagnosis may justify a separately billable O2Sat. Based on the results of the O2Sat, the physician may decide the patient warrants further (possibly immediate) services, such as inhalation treatment. Although this code does not create a Column 2 National Correct Coding Initiative edit, some payers may want modifier 59 Distinct procedural service appended to the secondary procedure.
  • Medication provided (e.g., J7613 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg, or J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME) ‒ When nebulizer treatment is provided, a medication is expended. Because the medication is dispensed in the doctor’s office (place of service code 11), the practice is allowed to bill for the drug separately.

Other Services and Conditions

  • A maximum breathing capacity/maximum voluntary ventilation study (94200 Maximum breathing capacity, maximal voluntary ventilation) may be performed at the same session. Some payers may require billing the technical and professional components separately with modifiers TC Technical component and 26 Professional components.
  • A patient who has suffered asthma attacks over the past six months is diagnosed with acute exacerbation of asthma, confirmed by an O2Sat. Maximal voluntary ventilation (94200) and nebulizing treatment (94640), consisting of Duoneb 2.5 mg albuterol/0.5 mg ipratropium (J7620) ensues, with a peak flow meter (A4614 Peak expiratory flow rate meter, handheld) and nebulizer mask provided.
  • Continuous positive airway pressure (CPAP), 94660 Continuous positive airway pressure ventilation (CPAP), initiation and management), spirometry (e.g., 94010, 94060, or 94070), and other pulmonary procedures may be conducted with a nebulizing treatment. A handheld or provider-assisted peak expiratory flow meter (A4614), or (depending on the payer) a peak expiratory flow rate study (S8110 Peak expiratory flow rate (physician services)) may be provided.
  • Other drugs represented by HCPCS Level II codes J7604-J7685, popularly known as Accuneb®, Xopenex®, Proventil®, Brethine®, Azmacort®, and other brands or market labels, may be administered. If there are comorbid conditions such as laryngitis or pharyngitis, a throat culture (87880 Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A) may be performed at the same session.

Treatment During Non-traditional Hours

When an inhalation treatment is done outside of regular business hours, some payers may allow additional reporting of 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, weekends), in addition to basic service or 99051 Service(s) provided in the office during the regularly scheduled evening, weekend, or holiday office hours, in addition to basic service for services provided when the office is open during “non-traditional” hours. Check with each payer in your state or locality; some will accept 99050 on a Sunday or holiday, but won’t accept 99051 under any circumstances.

Repeated Treatment

  • Both the inhalation treatment (94640) and the medication code may be reported in multiple units. Sometimes, an initial treatment fails to provide the desired nebulizing effect and must be repeated. If a treatment is performed twice on the same date, add modifier 76 Repeat procedure or service by same physician or other qualified health care professional (as directed by an instructional note beneath the descriptor for this code) to the second occurrence, so the payer doesn’t think you made a duplication error. Some payers may allow or request 94640 x 2, or other variations of multiple treatments.
  • Code 94644 Continuous inhalation treatment with aerosol medication for acute airway obstruction; the first hour, with add-on code 94645 Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour (List separately in addition to code for primary procedure), represents a less common method of inhalation treatment administration.

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