Rule Category:

Billing
Ref: No:
2012-BR-0006

Version Control:
Version No. 3.0
Effective Date:
April 2012
Revision Date:
August 2015

Nebulization
Adjudication Rule
Table of content
Abstract Scope Adjudication Policy
Page 1
Page 2 Page 2

Adjudication examples
Page 2

Denial codes
Page 2

Appendices
Page 3

Approved by:
Daman

Abstract

Responsible:
Medical Strategy &
Development Department

For Members
Billing Rules are the adjudication rules, which are in compliance with official CPT, ICDCM and HAAD/CCSC coding guidelines.
A billing rule defines the minimum requirements to be met when a service is claimed for
a Daman beneficiary in terms of frequency, duration etc.
It explains the minimum required documentation to claim a service. It also defines the
coverage of a service under a particular insurance plan administered by Daman.

For Medical Professionals

This adjudication rules defines billing rules and documentation requirements for
reporting nebulizer treatment.
CPT code 94640 (Pressurized or non-pressurized inhalation treatment for acute airway
obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol
generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing
(IPPB) device]) for the first treatment.
For continuous aerosol inhalation treatment applied for an acute obstruction of the
airway report 94644 for the first hour of treatment and 94645 for each additional hour.
CPT code 94664, Demonstration and/or evaluation of patient utilization of an aerosol
generator, nebulizer, metered dose inhaler or IPPB device does not include the services
described by code 94640. If the services described in 94664 performed in addition to
the nebulizer administration, code it if medically necessary and is not overlapping with
nebulizer administration.
Evaluation and management code can be reported if significant, separately identifiable
evaluation and management service provided by the same physician.

Related Adjudication Rules:

None

Disclaimer
By accessing these Daman Adjudication Rules (the
AR), you acknowledge that you have read and
understood the terms of use set out in the
disclaimer below:
The information contained in this AR is intended to
outline the procedures of adjudication of medical
claims as applied by the National Health Insurance
Company Daman PJSC (hereinafter Daman).
The AR is not intended to be comprehensive,
should not be used as treatment guidelines and
should only be used for the purpose of reference or
guidance for adjudication procedures and shall not
be construed as conclusive. Daman in no way
interferes with the treatment of patient and will not
bear any responsibility for treatment decisions
interpreted through Daman AR. Treatment of
patient is and remains at all times the sole
responsibility of the treating Healthcare Provider.
This AR does not grant any rights or impose
obligations on Daman. The AR and all of the
information it contains are provided "as is" without
warranties of any kind, whether express or implied
which are hereby expressly disclaimed.
Under no circumstances will Daman be liable to
any person or business entity for any direct,
indirect, special, incidental, consequential, or other
damages arising out of any use of, access to, or
inability to use or access to, or reliance on this AR,
including but without limitation to, any loss of
profits, business interruption, or loss of programs
or information, even if Daman has been specifically
advised of the possibility of such damages. Daman
also disclaims all liability for any material contained
in other websites linked to Daman website.
This AR is subject to the laws, decrees, circulars
and regulations of Abu Dhabi and UAE.
Any
information provided herein is general and is not
intended to replace or supersede any laws or
regulations related to the AR as enforced in the
UAE issued by any governmental entity or
regulatory authority, or any other written
document governing the relationship between
Daman and its contracting parties.
This AR is developed by Daman and is the property
of Daman and may not be copied, reproduced,
distributed or displayed by any third party without
Damans express written consent. This AR
incorporates the Current Procedural Terminology
and Current Dental Terminology (CPT and CDT,
which is a registered trademark of the American
Medical Association (AMA), and the American
Dental Association (ADA) respectively), and the
CPT and CDT codes and descriptions belong to the
AMA. Daman reserves the right to modify, alter,
amend or obsolete the AR at any time by providing
one month prior notice.

National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Nebulization
Scope

services described by code 94640. If the

services described in 94664 performed in
addition to the nebulizer administration,
code it if medically necessary and is not
overlapping with nebulizer administration.

This adjudication rules defines billing rules and

documentation requirements for reporting nebulizer
treatment.

5. Evaluation and management code can be

reported
if
significant,
separately
identifiable evaluation and management
service provided by the same physician.

Adjudication Policy
Eligibility / Coverage Criteria

6.

Nebulizer treatments are covered for all health

insurance plans of Daman provided it is reasonable
and necessary for the treatment of an acute
respiratory illness or injury or to improve the
functioning of a malformed body member.

Always code green rain code for the unit of

drug administered in addition to the
nebulizer treatment CPT code.

Adjudication Examples

Always report medication with green rain codes

nebulized in addition to the administration CPT
codes.

Example 1
Question: A 4 year old asthmatic girl holding a
Thiqa card presents to family physician with cough,
shortness of breath and wheeze. Physician
diagnosed it as asthma exacerbation and two
nebulizer treatments with ATROVENT 0.025% is
given .She clears up and breathing is easier, and
evidently better.

Requirements for Coverage

Nebulizer administered should be medically
necessary in terms of acute diagnosis, duration and
frequency.
Nebulizer used to deliver humidification and or
oxygen is not covered by the CPT codes 94640,
94464 and 94465 and are not be coded by these
CPT codes.

Answer:
Nebulizer administration - 94640 X 2 times
Nebulizer Medication

- 1317-1289-001

Requirements for Coverage

Example 2

ICD and CPT codes must be coded to the highest

level of specificity.

Question: A 50 year old Asian male holding a basic

card presents to physician office with chest pain,
shortness of breath, running nose and wheeze.
Physician diagnosed it as acute bronchitis and
allergic rhinitis. Physician administered 1 hr of
continuous nebulizer treatment with ALBUTEROL.

Non-Coverage
Nebulizer treatments are not covered if not
medically necessary or noncompliant with coding
and billing rule.

Answer:
Nebulizer administration - 94644
Nebulizer Medication

Payment and Coding Rules

1. Code all diagnosis with highest level
specificity.
2. CPT code 94640 (Pressurized or nonpressurized inhalation treatment for acute
airway obstruction or for sputum induction
for diagnostic purposes [e.g., with an
aerosol generator, nebulizer, metered dose
inhaler, or intermittent positive pressure
breathing (IPPB) device]) for the first
treatment.

- 2078-5925-001

Denial codes
Code

3. For continuous aerosol inhalation treatment

applied for an acute obstruction of the
airway report 94644 for the first hour of
treatment and 94645 for each additional
hour.

Code description

MNEC-004

Service is not clinically indicated based

on good clinical practice, without
additional supporting diagnoses/activities

PRCE-010

Use bundled code

MNEC-005

Service/supply may be appropriate, but

too frequent

CLAI-012

Service/supply may be appropriate, but

too frequent

4. CPT code 94664, Demonstration and/or

evaluation of patient utilization of an
aerosol generator, nebulizer, metered dose
inhaler or IPPB device does not include the
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Date of Issue:

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Nebulization
Appendices
A. References
1. AMA CPT assistant
2. CPT coding book 2011
3. CCSC coding manual 2011
4. HAAD claims and adjudication rules
V2012

B. Revision History
Date
01-07-13

15-07-14

Change(s)
V 2.0: New template
1.
2.
3.

V 3.0
Disclaimer updated as per system
requirements
Restored original effective date

National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
Doc Ctrl No.:

TEMP/MSD-004

Version No.: 1

Revision No.:

Date of Issue:

08.05.2013

Page No(s).:

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