Coding Clues to Asthma Care Reimbursement

Vol. 12 •Issue 10 • Page 16
Allergy & Asthma

Coding Clues to Asthma Care Reimbursement

Many respiratory care providers have a difficult time figuring out what, when and how to bill in order to be reimbursed properly for the extra care, teaching and time associated with treating an asthma patient.

Does the following scenario sound familiar?

A patient presents with wheezing and difficulty breathing. He wasn’t exposed to anyone with an illness, never had this problem before, has been sick for 12 hours, and shows no improvement since this started.

The physician does a quick history and exam and orders a nebulizer treatment and pulse oximetry. Then, the patient is re-evaluated, another pulse oximetry is taken, and he receives another treatment.

The doctor completes the visit by doing a final exam and counsels the patient and parents concerning the diagnosis of asthma. He teaches them how to use a metered dose inhaler and gives instructions on other medications and advice on the overall treatment plan.

Coding for this scenario doesn’t have to be difficult, but many practices only code for the visit and maybe for the treatments — seldom for the other services performed.


Let’s break apart the scenario above. First, we possibly have an emergency visit in the office (99058: patient presents with wheezing and difficulty breathing). The patient is seen and promptly evaluated (99213: expanded history — duration, associated signs and symptoms; expanded exam — heart and lungs with a low complexity decision making; ordering of treatment).

We now have two breathing treatments (94640: pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes, e.g., with an aerosol generator, nebulizer, MDI or intermittent positive pressure breathing device).1

And before giving the initial breathing treatment, we had a pulse oximetry (94760: noninvasive ear or pulse oximetry for oxygen saturation, single determination) and another one following the second breathing treatment.1

After a discussion, there’s teaching on the MDI (94664: demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, MDI or intermittent positive pressure breathing device).1 Also, don’t forget about the medications used.2

The billing so far is: 99213, 99058, 94760 (twice), 94640 (twice) and 94664. We also have to include the medication codes such as J7619 for 1 mg of a unit dose of albuterol and A7019 for 10 mL of saline solution. In addition, there are the supplies for the nebulizer, including a disposable administration set (A7003) and an aerosol mask (A7015).3


But how can you be properly reimbursed for all of those codes? The answer is modifiers.

Most carriers now are accepting the standard Centers for Medicare and Medicaid Services (CMS) modifiers due to the Health Insurance Portability and Accountability Act regulations. You should utilize the following modifiers:

25: used only on the office visit to indicate a separately identifiable service

59: used on the pulse oximetry to indicate that this was a distinct and separate service and shouldn’t be bundled into another primary procedure

76: used on any procedure that was repeated subsequent to the original procedure on the same patient by the same doctor on the same day (as per CMS guidelines) .but without the wording “on the same day” by Current Procedural Terminology (CPT®) guidelines.

Pulse oximetry was bundled by Medicare two years ago into almost everything. However, many facilities fail to realize that it wasn’t bundled in CPT. Office staff need to pay close attention to differences like these so they don’t lose out on revenue from payors other than Medicare and Medicaid.

Although coding of pulse oximetry isn’t a high dollar amount (approximately $6 to $12 depending on the carrier), everyone should agree that any little bit counts.

Now, here’s the coding of the aforementioned asthma visit, with modifiers:

• 99213-25 for the expanded history and expanded exam

• 99058 for the emergency service

• 94760-59 for the first pulse oximetry and 94760-59, 76 for the second one

• 94640 for the first treatment and 94640-76 for the second one (note that if three are given, use 94640-76 with a quantity of 2 for the second and third treatments)

• 94664 for the teaching on the MDI; some carriers may reject this one as included into the treatment or visit, so you may need to add the 59 modifier to indicate it’s a separate service and shouldn’t be bundled into the primary procedure.

Document each time you re-evaluate the patient, the number of breathing treatments (and why you ordered more than one), the interpretations on the pulse oximetry, and your teaching instructions for the metered dose inhaler. The teaching of the MDI doesn’t have to be performed by the physician but has to be under direct supervision and documented appropriately.4


When the patient comes back to the office for further education, you should consider using time as the key factor. Each office visit code has an associated amount of time with it.

When you do counseling and/or coordination of care and it involves more than 50 percent of the visit face-to-face with the patient and/or family, then time can be used instead of the history, physical and medical decision making.

For example, a patient returns for a recheck on his asthma. He has improved and is using his MDI, and after the initial history/exam, you counsel him on further medication needs and asthma education.

Your history, physical and medical decision are a level 2 (99212: problem-focused history and exam and straightforward complexity decision making), but you spend 10 minutes on the history/exam and the remaining 15 minutes on the counseling.

Your code then would be a 99214 (requires detailed history/exam and moderate complexity decision making or more than 50 percent of 25 minutes spent face-to-face in counseling or coordination of care). Because you spent more than half the time in counseling, you would then code the higher level of care using time as the key factor.

This is probably the area in coding where most offices lose out on added reimbursement. In order to code basing the visit on time, you have to document the total amount of time spent, the amount of time spent in counseling, and what was discussed during that session.

This increase only may be a $20 or $25 difference for this one visit, but that will add up quickly in a year’s time. Some visits may go from a 99212 to a 99215 based on time, so watch your clocks — it does make a difference.


The only other code that might be used is the prolonged physician service codes (outpatient: 99354 for the first 30 minutes to 74 minutes and 99355 for each additional 30 minutes). These codes are considered “add-on” codes and are used when a physician goes above and beyond the normal visit.

For example, if you performed a level 3 visit (15 minutes) and you continued to monitor, evaluate and talk with the patient for another 30 minutes to 74 minutes, you also can code the prolonged physician service code. Remember: This one also requires you to document the time, and when doing the re-evaluations, it would be in-and-out time.

So take the difficulty out of your asthma coding by following the above rules, and you’ll be breathing easier with your reimbursement.


1. CPT 2003; Professional Edition.

2. Pediatric Coding Alert. 2003;6(2):9-10.

3. Pediatric Coding Alert. 2003;6(3):17-9.

4. Pediatric Coding Alert. 2003;6(2):10.

Holle is manager of professional fee services for the department of pediatrics, University of Michigan Health Systems, Ann Arbor.

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