skip to Main Content
Written by: Vester Gravley on Monday, May 23, 2016 Posted in:

Recent regulatory changes have brought current procedural terminology (CPT) coding to the fore in respiratory therapy. And like the fog spouting from the end of a nebulizer full of Mucomyst, the current chaos regarding CPT code 94640 is causing a similar stink in respiratory departments from east to west. As far as I can tell, there are three main reasons for the murky mayhem:

Too many coders in the kitchen

No less than three regulatory agencies over the last few years have deigned to define who, what, when, and how 94640 is an appropriate code. The American Medical Association (AMA), National Correct Coding Initiative (NCCI), and the Centers for Medicare and Medicaid Services (CMS) have each issued similar and related guidances that are not the same, completely confounding any cogent attempt at proper coding.

Encountering patients

Central to proper use of code 94640 is the question of what constitutes a patient encounter. Due to inconsistencies in the guidance, the answer ranges from the total patient admission (meaning that only a single nebulizer can be billed per patient stay) to only one nebulizer per patient visit per day (which is better, but you are still only billing one nebulizer per patient per day, far less than are actually ordered or administered). One critical question: Is CMS intentionally trying to put respiratory therapy departments out of business? How does this improve care for COPD patients and reduce 30-day readmissions? Are we really damned if we do and damned if we don’t, or is there just a need for a reasoned, level-headed interpretation of the guidelines while we await forthcoming regulatory clarification?

Are you in or out?

The  “Coding Guidelines for Certain Respiratory Care Services” from the American Association of Respiratory Care (AARC) states, “The following information applies to inhalation treatments administered to Part B patients (i.e. outpatient hospital services). This includes emergency room patients who are not admitted to the hospital.”(1) Among the CPT codes listed is “94640 – Pressurized or non-pressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes.” So why all of the mystification surrounding inpatient nebulizer therapy? If the inpatient stay is “paid under a prospective payment system in which items and services provided to hospital inpatients are categorized into a diagnosis-related group (DRG), regardless of the number of conditions treated or services provided,” as the AARC asserts in the same document, then why the application or misapplication of outpatient guidelines to the inpatient stay?

Hopefully, clear answers will distill themselves soon. Until then, it may be helpful to recall the words of Joseph Conrad who reflected, “It is not the clear-sighted who lead the world. Great achievements are accomplished in a blessed, warm mental fog….”


  1. “Coding Guidelines for Certain Respiratory Services,” p. 4; American Association of Respiratory Care;
Back to top