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Nebulizer (94640) inclusive to E/M (99214) ?

Lori Posted Wed 30th of March, 2011 20:21:28 PM

I currently have an insurance carrier denying the nebulizer treatment (94640) indicating it is inclusive to the office visit. When reviewing the 2011 CPT book 94640 is listed under "Other Procedures" with this statement: "Codes 94010-94799 include laboratory procedures and interpretation of test results. If a separate identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported in addition to 94010-94799." I have never had a denial for this reason until now. I believe the statement in CPT could be interpreted differently. Does anyone have any insight?

SuperCoder Answered Thu 31st of March, 2011 15:51:55 PM

If a patient is scheduled specifically for a 94060, you can't also bill for an office visit. If during a patient exam the physician decides to perform 94060, you cannot also bill for an office visit. If during a patient exam the physician decides to perform a 94060, you can bill for both. However, when billing for both an office visit and 94060, the office should document everything (history, exam, medical decision making, etc.) within the patient's medical record and append modifier-25 to the office visit CPT code. Modifier -25 states: Significantly separately identifiable E&M service above and beyond the service provided.

Given the above conditions, still if you get denials, then the only way to get reimbursement in such cases is to convince the Insurance with Letter of Appeal justifying your documentation to the above criteria.

Marilyn Answered Thu 31st of March, 2011 18:48:09 PM

If a patient comes in with coughing and diagnosed with bronchitis and or ashtma, also is fatigued, and also seen for diabetes, then the Dr. decides to perform "94060", I can bill for the E/M correct? Of course, 94640 is also done but not billed for it is included in "94060" (?)

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