Physician's Intent to Treat Obstruction? Choose 94640

Coding scenario: An established patient with emphysema presents the office complaining of shortness of breath. The pulmonologist provides inhalation treatment and at the same time educates the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision making of low complexity. What code should we use in this situation?

Well, you should consider two CPTs to report this service. In the first instance, you would bill 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [example with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) to cover the wide-ranging service the physician provided.

Here's why: The best option is 94640 as the physician's primary intent was to treat the obstruction. If you report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device), you would risk a denial.

For the office visit, you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient …) based on your documentation of an expanded problem-focused exam with low complexity decision-making. You might need to add modifier 25 to 99213 to indicate that theE/M service was significant and separately identifiable from 94640.

Coding tip: Even though technically not required, it may help to link separate diagnosis codes to the E/M and the nebulizer treatment. For example, you could link 786.05 (Shortness of breath) to 99213, and link the emphysema code (492.8, Other emphysema) to 94640.