Coding for multiple nebulizer treatments is one of our “dual rule” issues where Medicare and other carriers who follow Medicare guidelines, differ from the AMA’s CPT™ instructions.

As of CPT 2016, CPT code 94640 describes treatment of acute airway obstruction with inhaled medication and/or the use of an inhalation treatment to induce sputum for diagnostic purposes. The language change was to clarify the intent that this be a “bundled code” representing both the diagnostic and therapeutic services. It does NOT however bundle multiple units.

According to the CPT™, when a patient receives multiple aerosol treatments on the same date, you should use 94640 for the first treatment and repeating subsequent treatments with the same code as a separate line item and adding require modifier 76 (Repeat procedure by same physician).

Therefore, you would code the example of two consecutive nebulizer treatments as:

  • 94640–first treatment
  • 94640-76 x 1 subsequent treatment.

For the inhalation solution, you should report two units of J7613 (Albuterol, inhalation solution, administered through DME, unit dose, 1 mg). Because J7613 represents one -unit dose.

A standard treatment session takes about 10 minutes and the patient should see some relief within 15 minutes. We understand from our physicians that one additional application is fairly common in the clinical setting especially in Urgent Care settings.

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

While CMS agrees with the rationale that code 94640 represents both the diagnostic and therapeutic services, they also ignore the AMA guidance and bundle multiple units.

Medicare: NCCI Policy Manual -2018; Chapter 11, J8. Page 26. CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction…) describes either treatment of acute airway obstruction with inhaled medication or the use of an inhalation treatment to induce sputum for diagnostic purposes.

CPT code 94640 shall only be reported once during an episode of care regardless of the number of separate inhalation treatments that are administered. (Under Medicare regulations, an episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.)

If CPT code 94640 is used for treatment of acute airway obstruction, spirometry measurements before and/or after the treatment(s) shall not be reported separately. The inhaled medication may be reported separately however, depending on the payer’s rules, the medication may also be bundled to the service.

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 typically 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)

In summary, mark this code as having one unit billing for Medicare but multiple sessions to most major medical carriers. Remember to “justify” an additional session in your notes by showing incomplete relief from the first dose after a reasonable expected response time (ie 15-20 min).

After decades of monitoring the annual Medicare therapy caps and temporary exceptions fiascos, I got an early morning call from a Washington DC friend contact that Congress had finally “repealed” the cap on therapy services.

It was well into the early morning hours when the Senate finally voted 71-28 to pass a budget bill known as the Bipartisan Budget Act of 2018 .

I knew word would spread fast and my phone would soon start ringing so I quickly reviewed the bill’s language and found we still had a cap at $2010 but it had been changed back to a “soft” cap and the exception process missing from the previous legislation in January, had now been provided.

Section 50202 – Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy – The new law requires for services after December 31, 2017:
* Medicare claims are no longer subject to the therapy caps (one for occupational therapy services and another for physical therapy and speech-language pathology combined);
* Claims for therapy services above $2010, the same amount as the previous therapy caps, must include the KX modifier indicating that such services are medically necessary as justified by appropriate medical record documentation; and
* Claims for therapy services above $3,000 of incurred expenses may be subject to targeted medical review.

So, the threat of a hard cap is gone and Medicare beneficiaries can still obtain necessary therapy services beyond the $2,010 limit as long as you affix the KX modifier to the claim.

Discipline Modifiers:
CMS also implemented a requirement for billing therapy services by ANY PROVIDER. (MM101076) effective 1/1/2018 set an additional billing requirement for any “always therapy” service provided by any provider specialty type. The instruction informed all providers that each code designated as “always therapy” must always be submitted with one of the therapy discipline modifiers GN, GO or GP in addition to any other relevant payment modifier like the KX modifier.

Based on this policy change, even a chiropractor providing an always therapy service must append the appropriate therapy modifier (normally GP) for the service being billed IN ADDITION TO modifier GY to indicate the service is non-covered by Medicare for their provider type.

Many Chiropractic offices are having claims “rejected” by CMS rather than being “denied and forwarded” to the secondary insurance just because they did not append the default GP discipline modifier to the therapy line items.

A rejected claim does NOT PROCESS through the system at all and therefore does not generate a valid denial for purposes of collection from the patient or their secondary coverage carrier. Offices that are not following the new reporting requirements have found themselves in a revolving door of re-submissions.

If, on any claim from any provider, one of the therapy modifiers, GN, GO or GP, is not appended then the claim will reject and not process through the Medicare processing system for denial.

You will need to refile the claim with the appropriate modifiers for it to process for denial.

The last battle: To offset future costs associated with eliminating the hard cap, Congress also enacted a payment differential for PTAs and COTAs like that used for Physician Assistants and Nurse Practitioners, which means therapist assistants will be reimbursed 85% of the amount PTs and OTs receive for the same services.

This reduction is set to go into effect on January 1, 2022 and will have more impact on “facilities and rehab agencies” than the Part “B” office setting where direct supervision of an enrolled PT or OT is required.

Baring any legislative actions to the contrary, we should be firmly set on the issues of caps and exceptions until the end of 2027.

Can I Treat My Partner’s Mother and Bill Medicare?

By R.L. “Ron” Ramsdell, PhD, FACFEI, DABFE, CFC, LFMAAMA.

The regulations on treating immediate relatives are found in the Medicare Benefits Policy Manual, Pub 100-02 in Chapter 16 (General Exclusions From Coverage) Section 130.  To better understand these regulations, you must first be familiar with the definitions of “provider and supplier” as used in all Medicare regulations.

Provider is defined at 42 CFR §400.202 and generally means a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency or hospice, that has in effect an agreement to participate in Medicare; or a clinic, rehabilitation agency, or public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology services; or a community mental health center that has in effect a similar agreement but only to furnish partial hospitalization services.

Supplier is also defined in 42 CFR §400.202 and means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.

In general, Medicare excludes payment for services rendered by a physician or other practitioner not only to their own immediate relatives but also to relatives of the owner or owner’s of the practice entity. (130-A.)

The intent of this exclusion is to bar Medicare payment for items and services that would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge. This exclusion applies to items and services rendered by providers to immediate relatives of the owner(s) of the provider. It also applies to services rendered by physicians to their immediate relatives and items furnished by suppliers to immediate relatives of the owner(s) of the supplier.”.

 Immediate Relative, as defined in regulations includes;

  • Husband and wife;
  • Natural or adoptive parent, child, and sibling;
  • Stepparent, stepchild, stepbrother, and stepsister;
  • Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law;
  • Grandparent and grandchild; and
  • Spouse of grandparent and grandchild.

There are some minor exceptions but basically these prohibitions also survive divorce or death of the actual relative.  In a stated example within the regulations, (130 B.) we see;

“For example, if a provider treats the stepfather of the owner after the death of the owner’s natural mother or after the owner’s stepfather and natural mother are divorced, or if the provider treats the owner’s father-in-law or mother-in-law after the death of their spouse, the services are considered to have been furnished to an immediate relative, and therefore, are excluded from coverage.”

Current regulations also extend to “members of the patient’s household” who share a single family unit dwelling and includes their (live in) domestic employees.

 “These are persons sharing a common abode with the patient as a part of a single family unit, including those related by blood, marriage or adoption, domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.”

The prohibition of payment for services rendered to the immediate relatives is quite broad and applies whether the provider or supplier is a sole proprietor or a partnership in which even “one of the partners” is related to the Medicare patient and extends to any “incident to” services that may be provided by a nurse or technician.(130 E)

What if my PA or NP treats the relative?

Under Medicare regulations, 130 F, “This exclusion applies to charges imposed by a non-physician supplier that is not incorporated, whether the supplier is owned by a sole proprietor who has an excluded relationship to the patient, or by a partnership in which even one of the partners is related.”

Under regulation 130 D, Regulations state;  “Professional corporation means a corporation that is completely owed by one or more physicians, and is operated for the purpose of conducting the practice of medicine, osteopathy, dentistry, podiatry, optometry, or chiropractic, or is owned by other health care professionals as authorized by State law. Any physician or group of physicians which is incorporated constitutes a professional corporation.”

 The regulations provide an “exception” for the stockholders, officers or directors of a corporation (other than a professional corporation) however you should definitely check with a competent healthcare law attorney for a legal opinion on how your “particular corporation” would actually be viewed under the Medicare rules.

Summary: The Medicare regulations would appear to prohibit your billing for services rendered to your partner’s mother or any other immediate relative of any partner within your practice.  I would suggest you refer the patient to a physician that is not associated with your practice or provide the care at no cost to anyone.

 The discussion presented above is offered only as an overview of Medicare regulations and is not intended to be, or construed by the reader as being a legal opinion or legal advice.  Private carrier policies may vary in coverage on this subject.  While the author has made a good faith attempt to present the discussion accurately, the discussions presented are base on lay-interpretation of the issues and should not be viewed as an attempt to offer or render legal advice or opinion or otherwise engage in the practice of law.  The discussion presented is, at best, of a general nature and cannot be substituted for the advice of a licensed attorney at law with specialized knowledge in healthcare regulatory issues.
 The M.A.A.M.A. and the Medcorp Compliance Network always advise physicians and other practitioners to seek the advice and legal opinion of a licensed healthcare law attorney in your home State as your only authoritative interpretation of all matters of law and regulation for Federal, State and individual carrier coverage issues.


Q&A with Dr R.

Our doctor uses electo-acupuncture to break up trigger points.  Can I bill this under the TPI code 20552-20553 to Medicare or others.

NO. Acupuncture is not a covered service for Medicare, even if provided for the treatment of an established trigger point. Use of acupuncture needles and/or the passage of electrical current through these needles is not covered regardless of who is doing it.   For your major medical carriers, acupuncture with electrical stimulation is a stand-alone service billed under 97813-97814 based on the “time component” of 15 minute increments.  The actual “focus” of the procedure does NOT affect the billing code.

CodingCoding Alert for P-Stim™ AGAIN!

Writing for the Academy:  R.L. Ramsdell PhD, FACFEI, CFC, DABFE, LFMAAMA. Executive Director.

March 21, 2014

We are once again receiving coding questions and issues regarding the P-Stim™.

We originally published a special alert for this product on September 15, 2013 when members reported the sales representatives were recommending CPT 64553 “implant” code for the procedure and a billing of L8680 for the electrodes.

In our original alert to our members, we stated;

The Academy has received many recent inquires on the proper coding for electrical stimulation of auricular acupuncture points using the P-Stim™ device.  Various coding scenarios were submitted from concerned members, including “stealth” coding using implant codes, as offered by some sales representatives as well as their claims of “coverage” by “Medicare and Most Major Medical Plans”.

Our investigations have shown these claims for the most part, are false and may be designed to create an unrealistic anticipation of payment and/or offer various “stealth coding” scenarios that could qualify the procedure for payment based solely on submission of inaccurate codes BUT would put the practitioner “at significant risk” for allegations of fraud or abuse on audit.

According to recent member reports, the sales people have now “altered” their coding suggestion to use CPT implant code 64555 for the procedure and E1399 for the electrodes.

First, let’s look at the FDA approval for the unit.  You can view it for yourself at:

  • Trade or Proprietary Name: P-Stim
  • Common Name: Electro-acupuncture device
  • Classification Name: Electro-acupuncture stimulator
  • Classification: Unclassified

Predicate Device: The legally marketed predicate device to which the P-Stim is substantially equivalent is the Acu-Stim (KO14273).

Intended Use:The P-Stim is intended for use as an electro-acupuncture device to stimulate appropriate auricular acupuncture points.

Device Description: The P-Stim is a miniaturized, battery-powered, transcutaneous electrical nerve stimulator that has a pre-programmed frequency, pulse, and duration for the stimulation of auricular acupuncture points.

The device connectsvia three stainless steel wires to acupuncture needles that have been applied to the appropriate auricular acupuncture points. The device is powered by three zinc air batteries, each with a voltage of 1.4 V. The device is on for 180 minutes, then off for 180 minutes, for a maximum period of up to 96 hours.

Based on the unit’s approval and accepted indications, we must again stress the most “basic instructions” on code selection contained in the CPT manual that prohibits misrepresentation through “stealth” coding.

Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.

Medicare entertained a request from P-Stim in their May 29, 2013 HCPCS Meeting.  Agenda item #6 Stated; Topic/Issue:Request to establish a new Level II HCPCS code to identify a miniaturized device designed to administer auricular point stimulation treatment over several days. Trade name: PSTIM. Applicant’s suggested language: “P-STIM: percutaneous auricular neurostimulator with 3 needles; used for before and after measurements of sympathovagal balance”. According to the requester, the P-STIM is a miniaturized device designed to administer auricular point stimulation treatment over several days. Point stimulation by the P-STIM is mainly used to treat pain. The P-STIM is a wearable device this is designed to administer continuous pulses of a low-level electrical current at the ear over several days. Electrical pulses are emitted though three selectively positioned acupunctures needles. The P-STIM is worn for four days on and three days off and is removed by the patient on the fourth day. The average patient usually requires 1-12 weeks of treatment. According to the requester, the patient population for which the device is clinically indicated is patients who suffer from diagnosis as: migraine, chronic pain (lower back or otherwise), shingles, fibromyalgia, refractory neuropathy, central sensitization disorders and PTSD.  The decision was; A national program operating need was NOT identified by Medicare, Medicaid, or the private insurance sector to establish a code to identify this device. Based preliminary benefit category analysis, we believe that there would be NO Medicare payment for these items.

Major Medical Coverage:

Non-coverage of the services may be found in their Acupuncture policies, complementary and alternative medicine or, if specifically addressed, like with the “Blues”, in a policy for “CRANIAL ELECTROTHERAPY STIMULATION (CES) AND AURICULAR ELECTROSTIMULATION”. Others, like Health Net, for example, just include the service under their non-payable “investigational procedures” listing.


Opinion on the use of CPT implant code 64555 for the procedure and E1399 for the electrodes. 

 In reviewing the literature and rationale from the company, we see that they are making a “leap” to now declare the unit to be a “percutaneous electronic nerve stimulator” (PENS) and applicable to the coverage provisions and coding applicable to those units INCLUDING the implant procedure code 64555  Percutaneous implantation of neurostimulator electrodes; peripheral nerve.

We must again take exception with the rationale, based both on the coding and on the “off label” use that exceeds the FDA approval of the unit as an electro-acupuncture device to stimulate appropriate auricular acupuncture points.

We must also take exception that the electrodes are “implanted” when the FDA 510(k) approval specifically states “The P-Stim™ device connects to 3 inserted acupuncture needles with caps and wires.”

Typically carriers interpret “implant” as being a surgical procedure way beyond an “insertion” of needles.

Last, we must object to assuming that the implant is to the “nerve(s)” since the approval also specifies that the use of the “stylus” is to identify the appropriate auricular acupuncture points.

Academy Conclusion On Proper Coding:  Based on the available evidence, the Academy finds that the representative claims that “P-stim is reimbursed by Medicare and Most Major Medical Plans” and should be billed under the 64555 code are inaccurate.

The Academy therefore suggests the following as “applicable” to the P-Stim™


  • 97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
  • 97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)

HCPCS:  Is the Most specific.

  • S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with the patient.
    • (Developed and became effective April 1, 2012.)

There is no specific supply code for the unit(s) and therefore you would use E1399 with a description of “P-Stim electro-acupuncture device”.

In our opinion, billing for application of the unit under 64555 is NOT appropriate and such reporting should be restricted to 64999 with an accurate description of the procedure to avoid any misrepresentation to the carrier.  We remind everyone that the fact you billed using an approximate fit code which was paid, does NOT mean you billed it correctly.   For example, Medicare will pay the codes you billed because they are valid codes and they are assuming those are the procedures you performed. Your PAIN will come with audit when your notes do NOT support a surgical implant.

We also feel proper billing for the supplies (unit kits) should be reported under the E1399 NOS supply code or CPT general supply code 99070, with an accurate description of “electro-acupuncture device” including the unit name.   Most carriers will expect you to submit an invoice with the claim.   

We feel any other coding scenarios would be a misrepresentation of the service performed, subject to recovery upon carrier audit and possible allegations of fraud or abuse.  

Again, our opinion here is on the “Coding” ONLY and not the quality or efficacy of the actual equipment, technology or potential therapeutic benefit to the patient.

Members should consider the potential benefit to the patient within the reality of a “non-covered service” and provide the patient with applicable notice of personal liability.