7 Services PCPs Forget to Bill For

Betsy Nicoletti, MS


June 12, 2018

In This Article

Other Sources of Lost Revenue

5. Pulmonary Services

There are two pulmonary services that are a large source of lost revenue for medical practices and urgent care centers. The first is a nebulizer treatment and the medication used in the treatment, and the second is for education regarding the use of an inhaler or nebulizer at home. Medical practices regularly forget to bill for the nebulizer and medication.

When a patient presents with wheezing or shortness of breath, and a nebulizer treatment is done in the office, there should be three charges billed: a charge for the E/M service, a charge for the nebulizer treatment itself, and a charge for the medication used in the nebulizer treatment. Two of these are CPT codes, and the medication is an HCPCS code, typically albuterol.

The code for the nebulizer treatment is, "94640 Pressurized or nonpressurized 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." There are two dosage-related codes for inhaled albuterol. Use J7613 for, "Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg." And use J7620 for, "Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME."

The second service is education by staff about use of a nebulizer or other home pulmonary treatment. Use 94664 for this service. This is defined in CPT as, "94664 Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device." This is a service that is often performed by clinical staff members, incident to the physician's service. In some instances, however, it could be performed by the physician.

Why are these overlooked? While most practices remember to bill for the nebulizer, the education code is more frequently overlooked. Groups don't know that a code exists to describe this important patient and family education.

Code Description wRVUs National Non-facility Payment
94640 Airway inhalation treatment 0 19.07
94664 Evaluate patient use of inhaler 0 17.64
J7613 Albuterol via DME unit dose 1 mg   0.05
J7620 Albuterol and ipratropium bromide, via DME   0.15

6. Fracture Care Codes

When a medical practice treats a patient with a nondisplaced fracture, with or without manipulation, the practice has the option to bill an E/M service or to select a code from the musculoskeletal chapter for treatment of a nondisplaced fracture.

Some of the fracture care codes have 10 global days, but most have 90 global days. That means that the practice is paid for the follow-up care as part of the global payment and does not bill for those follow-up visits related to the fracture. These codes are used when definitive, restorative treatment is provided. Typically, these fracture care codes have a higher reimbursement than billing for the initial and follow-up E/M services.

Because there are so many different potential codes to us, it's best to look up the fracture care codes by type of fracture in the CPT book.

Why are these overlooked? Outside of orthopedic practices, the rules related to fracture care aren't widely known. There is confusion about the follow-up visits and whether they are part of the fracture care payment or not. And these codes can be difficult to find in the EHR.

7. Consults

Many physicians remember that, in 2010, Medicare stopped recognizing consultation codes. Medicare Advantage plans followed suit quickly, as did managed Medicaid programs.

However, many commercial insurers still recognize and pay for office/outpatient consultations and inpatient consultations. Following Medicare rules on consultations for all payers is a source of lost revenue and lower RVU production. Some medical practices stopped in order to simplify the coding and billing process. However, the payment for consultations from payers that still recognize consults makes it worthwhile to continue to bill for the services.

Consultations are not defined as new or established patient visits. CPT defines a consult as follows: "A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem."

Any specialty provider may bill a consult, if the requirements for a consultation are met. Document the request for the consult using the requesting clinician's name and the reason for the consult, and make sure that a copy of the report is sent to the requesting clinician.

Why are these overlooked? Many coders and physicians assumed that all commercial payers would follow Medicare and stop reimbursing for the service. While some did, many major national payers still recognize the codes. It can be difficult for a practice to develop a process for the physicians so that physicians don't have to remember which codes to bill.

The best process is to ask the practitioners to bill consults when a consult is provided and documented, and the billers should set up an edit for consult codes and cross walk them to other E/M services for Medicare.

Code Description wRVUs National non-facility payment
99241 Office consultation, level one 0.64 48.23
99242 Office consultation, level two 1.34 90.69
99243 Office consultation, level three 1.88 124.17
99244 Office consultation, level four 3.02 185.71
99245 Office consultation, level five 3.77 226.38
99251 Inpatient consultation, level one 1 49.67
99252 Inpatient consultation, level two 1.5 75.94
99253 Inpatient consultation, level three 2.27 116.97
99254 Inpatient consultation, level four 3.29 169.87
99255 Inpatient consultation, level five 4 204.42

Collecting revenue for medical practices services is hard work. Don't compound the problem by not billing for services performed and documented in the office.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.