Q: What can we bill for when we give a patient a nebulizer treatment for an acute airway obstruction during an exacerbation of asthma, or wheezing due to an upper respiratory ailment?
A: You can bill for the service and the medication. However, depending on the payer rules, the medication might be bundled into the service.

Time is a factor when billing the service. If the treatment is less than 1 hour, you would bill Current Procedural Terminology (CPT) code 94640, “Pressurized or non-pressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device.”

Effective January 1, 2017 the Centers for Medicare and Medicaid (CMS) has changed its policy regarding multiple inhalation treatments (CMS National Correct Coding Initiative [NCCI] Edits Policy https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html, Chapter 11, page 25). The policy states that an episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility. CPT code 94640 should be reported only once during an episode of care, regardless of the number of separate inhalation treatments that are administered. This means that if the patient requires two separate nebulizer treatments during the same visit, you would still only bill CPT code 94640 once.

However, if a patient receives “back-to-back” nebulizer treatments exceeding 1 hour, (which rarely occurs in urgent care), bill CPT code 94644, “Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour,” and CPT code 94645, “Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour,” as appropriate, instead of CPT code 94640.

If the patient receives a nebulizer treatment of less than 1 hour (CPT code 94640) during an episode of care and subsequently returns on the same date of service to the urgent care to receive another nebulizer treatment of less than 1e hour, then you would bill CPT code 94640 and append modifier -76, “Repeat procedure or service by same physician or other qualified health care professional” for the second treatment, since the return visit would be considered a separate episode of care.

CPT code 94640 cannot be billed on the same date of service as CPT codes 94644 and 94655.

The medications administered in the urgent care setting are most commonly a form of albuterol. You will find the correct codes to use in the “Healthcare Common Procedure Coding System Level II” (HCPCS) coding manual. Below is a list of Federal Drug Administration (FDA)-approved medication containing albuterol:

  • J7611, “Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg”
  • J7612, “Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DEM, concentrated form, 0.5 mg”
  • J7613, “Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg”
  • J7614, “Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg”
  • J7620, “Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME”

There are several respiratory or pulmonary conditions that may qualify for inhalation treatment coding, such as:

  • Asthma, (J45.-)
  • Acute bronchitis, (J20-)
  • Chronic obstructive pulmonary disease (COPD), (J44-)
  • Pneumonia, (J18.-)
  • Acute bronchospasm, (J98.01)
  • Cough, (R.05)
  • Wheezing, (R06.2)
  • Shortness of breath, (R06.02)

Let’s look at a visit scenario: A 20-year-old patient presents with a cough that has lasted the past 5 days. A review of her past medical record shows she was seen in your clinic about a year ago for similar symptoms. You note that her oxygen saturation is at 96% on room air, and you hear a slight wheezing in her lungs. After examination, you order the administration of 0.63 mg/3 mL of levalbuterol tartrate (Xopenex). The treatment takes 10 minutes to complete. The patient is still in distress, so the treatment is repeated and completed within 15 minutes. A new reading of her oxygen saturation is remarkably improved at 99% on room air. The patient is feeling much better after the treatment. The final diagnosis is determined to be acute bronchitis, and prescriptions are written for azithromycin and an albuterol sulfate inhaler. The claim will show the following diagnosis and procedure codes:

  • 9, “Acute bronchitis, unspecified”
  • 99214 with modifier -25 (example assumes a detailed history, detailed exam, and moderate medical decision-making)
  • 94761 (multiple oxygen saturation readings)
  • 94640 (nebulizer treatment)
  • J7614 X 4 units (Xopenex, 0.5 mg per unit)

Note that CPT code 94640 is billed only once because the two treatments were performed during the same episode of care.

However, if later that same day the patient returned to the clinic due to continued breathing problems and the same nebulizer treatment was provided using the same medication and dosage as before, you would bill CPT code 94640 with modifier -76 for the treatment, along with HCPCS code J7614 for the medication, as this would be a separate “episode of care” as defined by CMS.

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