Respiratory Compliance Question of the Week
Archive
To return to the current Respiratory Compliance Question of the Week, click here
September 29, 2008
Question:
I heard from a colleague that in 2009 Medicare will not always pay for
CPAP. Is this true, and what are the conditions for payment?
Answer:
On June 30, 2008, CMS proposed (in the 2009 Medicare physician fee schedule [MPFS]) to limit Medicare payment for continuous positive airway pressure (CPAP) under certain conditions. If the CPAP supplier, or its affiliate, "is directly or indirectly the provider of the sleep test used to diagnose a beneficiary with sleep apnea" reimbursement would be limited.
Apparently, CMS is concerned about over utilization and believes that the
entity that administers the sleep test and/or provides the device used to
administer that test has a self-interest in the results when that entity
is also the device supplier."
For a PDF version of the 2009 proposed MPFS rule, go to http://edocket.access.gpo.gov/2008/pdf/E8-14949.pdf.
The information related to CPAP can be found in the second column on page
38579.
-------------------------------------------------------------------------------
September 22, 2008
Question:
I am confused about the answer to the respiratory question posted on September
8. You said that respiratory services are covered as ancillary services
under the inpatient hospital benefit when provided by a respiratory therapist
(RT) or technician. You also said that if a nurse provided the service,
it would be covered under the inpatient hospital benefit.
Can you clarify whether additional charges may be generated for the encounter
for the RT and/or the nurse?
Answer:
Medicare makes one payment for inpatient services based on MS-DRG assignment,
and this payment does not increase when a RT service is billed. If the service
provided meets the definition of an ancillary service, the RT may bill for
it and, therefore, generate a charge for the encounter. To be considered
an ancillary service, the documentation must confirm that the skill of a
trained RT is necessary. Specifically, this would be an acute airway or
therapy that requires intervention and is above and beyond the level of
"routine" nursing services (e.g. incentive spirometer or other
routine service typically performed by the patient but overseen by either
RT or nurse).
Delivered services that do not require the expertise and skill of a trained
therapist and that can be performed as a nursing care service are part of
the room and board charge for the patient's daily care. There is no additional/separate
charge added to the claim for this routine therapy.
Regardless of whether the routine therapy or service is overseen by RT
or nurse there should not be an additional/separate charge.
For inpatients, both the ancillary service of the RT and the cost that is bundled to the room and board or per-diem charge are services that are included in the single payment received for the MS-DRG level.
-------------------------------------------------------------------------------
September 15, 2008
Question:
For CPT 95810 (polysomnography, four or more), the hospital outpatient PPS APC rate is $718.61 and the Medicare physician fee schedule (MPFS) rate is $826.87 (technical component [TC] of $646.72 and professional component [PC] of $180.15).
How does a lab bill for this? For example, if we conduct a sleep study, do we bill the APC rate or the TC of the MPFS rate? And does the physician then bill only for the PC of the MPFS rate?
My experience is inpatient, and I am unclear on the difference between
the APC rate, and the TC of the MPFS, and in what circumstance each would
be used or not used.
Answer:
When billing for an outpatient prospective payment system (OPPS) hospital, sleep studies are reported on Medicare's CMS-1450 form. The dollar amount reported on the claim will represent the facility cost for providing the service (room time, technician time, equipment, etc) but does not include the cost of the physician's interpretation. From a payment perspective the hospital cost (facility fee) will be reimbursed by Medicare at the APC rate, but you should not assume that the hospital is limited to reporting a charge equal to the APC rate.
The MPFS reimbursement rates are representative of Medicare payments for a sleep study occurring in a physician clinic or independent diagnostic testing facility (IDTF). This information would be communicated to the payer by the "place of service" reported on the CMS-1500 form, which may carry either a global fee for the sleep study that combines both the TC and PC (modifier 26), or it may report each separately.
When the sleep study is provided in the hospital outpatient department the service will be "split billed," meaning that the hospital will report the facility fee on the CMS-1450 with the physician fee for interpretation being reported on the CMS-1500. If the physician services are billed by the hospital, the hospital should submit the CMS-1500 form, and the physician will be paid "under contract" by the hospital for providing the interpretation of the sleep study. Regardless of who submits the CMS-1500 the billing entity will be reimbursed by Medicare at the rate established in the MPFS for the professional component.
-------------------------------------------------------------------------------
September 8, 2008
Question:
For a respiratory service delivered to a hospital inpatient, Is there
any difference in payment when a therapist provides the service or when
a nurse provides it?
Answer:
When a respiratory therapist or technician furnishes respiratory or pulmonary function services, the services are covered as ancillary services under the inpatient hospital benefit. When a nurse furnishes these same services, the service would constitute nursing services and would be covered as such under the inpatient hospital benefit. In both instances, payment for the services provided is captured in the MS-DRG payment.
-------------------------------------------------------------------------------
September 1, 2008
Question:
What are the key points of the new policy you mentioned last week in response
to a question about the transfer of ownership of O2 equipment?
Answer:
After the 36th continuous month during which payment is made for the equipment,
the following will occur:
- The supplier furnishing such equipment shall continue to furnish the equipment
during any period of medical need for the remainder of the reasonable useful
lifetime of the equipment, as determined by the Secretary;
- Payments for oxygen shall continue to be made in the amount recognized
for oxygen for the period of medical need; and
- Maintenance and servicing payments shall, if services are reasonable and
necessary, be made (for parts and labor not covered by the supplier's or
manufacturer's warranty, as appropriate for the equipment), and such payments
shall be in an amount determined to be appropriate.
For this information, go to HR 6331 can be found at
http://thomas.loc.gov/. Under "Search Bill Text," type HR
6331, and select "Bill Number" under that entry.
-------------------------------------------------------------------------------
August 25, 2008
Question:
What is the Medicare policy related to transfer of ownership of O2 equipment?
Answer:
This topic was addressed in the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 (HR 6331), enacted on July 16, 2008. In HR 6331, Congress provided a section entitled "payments and rules after rental cap" that is supposed to take effect on January 1, 2009. The provisions apply after the 36th continuous month during which payment is made for the equipment.
For this information, go to HR 6331 can be found at http://thomas.loc.gov/. Under "Search Bill Text," type HR 6331, and select "Bill Number" under that entry.
-------------------------------------------------------------------------------
August 18, 2008
Question:
Is it true that CMS will be developing standards for pulmonary rehab programs?
Answer:
The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 (HR 6331), enacted on July 16, 2008, addresses the topic of a physician-supervised pulmonary rehabilitation program. Congress directed the Secretary of the Department of Health & Human Services (of which the Centers for Medicare & Medicaid Services [CMS] is a part) to establish standards to ensure that a physician with expertise in the management of individuals with respiratory pathophysiology who is licensed to practice medicine in the state in which program is offered be responsible for the program. This physician should, says MIPPA, do so in consultation with appropriate staff.
HR 6331 can be found at http://thomas.loc.gov/. Under "Search Bill Text," type HR 6331, and select "Bill Number" under that entry.
-------------------------------------------------------------------------------
August 11, 2008
Question:
My question is about the code range 95805-95811 for sleep studies/polysomnography studies and your answer last week to the question regarding billing sleep studies using the 52 modifier.
If a patient is recorded for six hours but actually only sleeps for five
or less hours, should the 52 modifier still be used? I have received different
answers on this question form different people. I have been told that as
long as the patient is monitored for six hours or more the 52 modifier does
not have to be used even if the patient only sleeps five hours or less.
Your answer states if the patient is not asleep for the six hours of recording
time to reduce the service, is this correct?
Answer:
A. Below is the first sentence of the introductory paragraph in the CPT manual for sleep / polysomnography. The following sentence is the parenthetic instruction for use of the -52 modifier, which says to use if less than six hours of recording is achieved.
"Sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for 6 or more hours with physician review, interpretation and report."
"Report with modifier 52 if less than 6 hours of recording or in other cases of reduced services as appropriate."
In the CPT Assistant (September 2002) the American Medical Association estimates an overnight sleep study to require approximately 10 hours, producing approximately 1,000 pages of recordings. As states of drowsiness, intermittent wakefulness and / or restlessness and / or a patient's inability to reach full sleep may aid in determining the diagnosis, we would think that six or more hours of recording that reflects a genuine attempt to achieve sleep would be billable without the 52 modifier. Our interpretation is that modifier 52 applies to the number of hours recorded as this is equal to the work effort of the technician in monitoring the patient and also reflects the amount of material to be reviewed by the physician for interpretation.
-------------------------------------------------------------------------------
August 4, 2008
Question:
My question relates to sleep studies and CPT code 95807. Does the following statement from the CPT book apply to sleep studies and polysomnography or just to the statement above it for polysomnography? (Report with modifier 52 if less than 6 hours of recording or in other cases of reduced services as appropriate.)
Answer:
The first sentence of the coding guideline for this group of CPT (95805-95811) states: "Sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for 6 or more hours with physician review, interpretation and report."
When, for whatever reason and despite the best efforts of the therapist, the patient is unable to achieve six or more hours of documented sleep, the applicable CPT code is to be reported with modifier 52 appended to communicate to the payer that the full definition of the service was not meet.
-------------------------------------------------------------------------------
July 28, 2008
Question:
Can separate procedure code 94250 (expired gas collection, quantitative, single procedure) be reported with any of the respiratory therapy codes?
Answer:
Billing for the expired gas collection in addition to any of the respiratory therapy codes-94620, 94621, 94680 and 94681 as included in the CCI edits-will result in double billing and a claim denial. To report a determination for expired nitric oxide, refer to CPT code 95012.
-------------------------------------------------------------------------------
July 21, 2008
Question:
I would like to ask about sleep studies and CPT code 95807. A statement in the CPT manual states that modifier 52 should be reported if less than six hours of recording has been performed or in other cases of reduced services as appropriate. Does this apply to sleep studies and polysomnography (PSG) or just to the statement above it for PSG?
Answer:
The first sentence of the coding guideline for this group of CPT codes (95805-95811) states: "Sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for 6 or more hours with physician review, interpretation and report."
When, for whatever reason and despite the therapist's best efforts, the patient is unable to achieve six or more hours of documented sleep, the applicable CPT code is to be reported with modifier 52 appended. This communicates to the payer that the full definition of the service was not met.
-------------------------------------------------------------------------------
July 14, 2008
Question:
What guidelines can you provide for inpatient billing when a patient is on a CPAP for part of the day and after the CPAP is removed, the patient continues to receive oxygen for the remainder of the day. Is it appropriate to bill a full day of oxygen in conjunction with a charge for the CPAP?
Answer:
Bill for CPAP as the service is provided, even for a partial day. Bill for all oxygen delivered and documented during the day of service.
-------------------------------------------------------------------------------
July 7, 2008
Question:
Is it appropriate to submit a Medicare claim that includes both codes 94200 and 94010?
Answer:
Code 94200 (maximum breathing capacity, maximal voluntary ventilation [MVV]) is considered a component of codes 94010, 94060 and 94070. Billing code 94200 on the same date of service as any of these codes is considered to be double billing and will result in a denial.
-------------------------------------------------------------------------------
June 30, 2008
Question:
Since most of our sleep study patients come to the facility in the evening, are they considered to be inpatients?
Answer:
According to Highmark Medicare Services, most of the patients who undergo
diagnostic sleep testing are not considered inpatients although they come
to the facility in the evening for testing and then leave after their tests
are over. The overnight stay is considered an integral part of these tests.
See http://www.highmarkmedicareservices.com/faq/parta/sleep_disorders.html.
-------------------------------------------------------------------------------
June 23, 2008
Question:
What documentation should be submitted with a sleep study claim? Our center is in Pennsylvania.
Answer:
According to Highmark Medicare Services (Medicare Part A payer), the patient's
medical record is expected to include the following:
- Physicians orders
- Documentation of the patient's history/physical/medications
- Documentation of the specific signs/symptoms, level of functional impairment,
and other clinical data supporting the diagnosis codes used
- Documentation of the indications for performing sleep disorder testing
including the patient's symptoms of sleep disturbance and interference with
the patient's ability to function
- Results and interpretation of sleep disorder testing and all other testing
billed on the claim
- For polysomnography with CPAP titration, include the results of the initial
polysomnography along with documentation supporting the diagnosis of moderate
or severe obstructive sleep apnea
- Itemized bill
See http://www.highmarkmedicareservices.com/faq/parta/sleep_disorders.html.
-------------------------------------------------------------------------------
June 16, 2008
Question:
How will the new DMEPOS competitive bidding demonstration affect hospital payment for respiratory products?
Answer:
On July 1, the Centers for Medicare & Medicaid Services (CMS) begin
phasing in the new program for purchasing durable medical equipment, prosthetics,
orthotics, and supplies (DMEPOS). According to CMS, hospital reimbursement
may not be directly affected by the new program. However, Medicare coverage
for patients for whom hospitals order, refer, or supply DMEPOS will be affected.
Basically, Medicare beneficiaries residing in the designated program areas
must buy their DMEPOS from Medicare-contracted suppliers if Medicare is
to cover the cost. This may require some patients to switch from a non-contract
supplier to a contract supplier.
The following respiratory-related categories fall under the new program:
- Oxygen supplies and equipment
- Continuous positive airway pressure (CPAP), respiratory assist devices,
and related supplies and accessories
For comprehensive information on the DMEPOS competitive bidding program, go to www.cms.hhs.gov/DMEPOSCompetitiveBid.
-------------------------------------------------------------------------------
June 9, 2008
Question:
What is the proper way to bill for outpatient oxygen therapy?
Answer:
For outpatients, there is not a specific CPT code that describes this
service, and Medicare has not issued any specific coding guidance for it.
Some providers have reported this service using CPT code 94799-unlisted
respiratory therapy
procedure. Because many Medicare fiscal intermediaries (FIs) and Part A
Medicare administrative contractors (MACs) have targeted this code for focused
review, MedLearn recommends that you contact your payer to clarify its stance
on the proper use of this code for oxygen therapy services provided by qualified
respiratory therapists.
-------------------------------------------------------------------------------
June 2, 2008
Question:
How many times can code 94640 be reported for inhalation treatment for acute airway obstruction?
Answer:
You may report this CPT code multiple times for a single date of service (DOS). According to the parenthetical cross-reference included in the CPT code book, users are to append the modifier 76 when more than one treatment is administered on the same DOS. Physician orders must be documented for each treatment to support the charges submitted for reimbursement.
Billing for the individualized evaluation, instruction and training related to the proper and effective use of aerosol medications and the delivery device are discussed in the section for CPT code 94664.
-------------------------------------------------------------------------------
May 26, 2008
Question:
Our hospital billers would like to know what codes are component codes, according to the national correct coding initiative (CCI) of code 94060 (bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration).
Answer:
A. The national correct coding initiative (CCI) notes that the following codes are components of 94060: 94010 (spirometry), 94200 (maximal voluntary ventilation), 94375 (respiratory flow volume loop), 94640 (nonpressured inhalation treatment), 94664 (aerosol inhalation), and 94770 (CO2 by infrared). The CCI also indicates that the spirometry procedure as described by 94060 is a component of 94070 (post-exposure bronchospasm evaluation), and the pulmonary stress-testing procedures represented by CPT codes 94620 and 94621.
-------------------------------------------------------------------------------
May 19, 2008
Question:
We would like some information about codes 94014-94016, which relate to spirometric recordings initiated by the patient. Specifically, how should these be reported, and will they be paid by Medicare?
Answer:
According to the 2008 CPT manual, codes 94010-94799 include lab procedures and interpretation of test results. If a separate identifiable evaluation and management (E&M) service is performed, the appropriate E&M code should be reported in addition to one of these codes.
Generally, CPT codes 94014-94016 are considered not covered by Medicare since their clinical efficacy has not been established. However, many states do have local coverage policies for patient-initiated spirometric recording, and we recommend that you check with your Medicare payer for coverage polices relevant to your facility.
-------------------------------------------------------------------------------
May 12, 2008
Question:
I have heard about Medicare's new DMEPOS competitive bidding program, but do not know what supplies are affected for respiratory therapy. Can you answer this and provide a source for more information?
Answer:
Oxygen supplies and equipment in addition to continuous positive airway pressure (CPAP) devices and respiratory assist devices (RADs) and related supplies are included in the new program. .
As you may know, this program will be implemented in 10 regions of the country on July 1, 2008. If your patient lives in or travels to one of these 10 designated areas and you order, refer or supply any medical equipment or supplies that fall within 10 product categories, the patient must now get the equipment or supplies from a Medicare-contracted supplier.
You or your patient can find out if a supplier is included in the program
by visiting http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS.
For the latest provider information on this new program, CMS has released
three educational articles, which can be found at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0805.pdf,
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0806.pdf,
and
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0807.pdf.
There's also a Medicare fact sheet entitled "What You Should Know
if You Need Medicare-covered Equipment or Supplies" at
http://www.medicare.gov/Publications/Pubs/pdf/11307.pdf.
-------------------------------------------------------------------------------
May 5, 2008
Question:
Must maximal voluntary ventilation be performed to bill code 94010?
Answer:
Maximal voluntary ventilation (MVV) is optional. If you perform the MVV, you cannot bill CPT code 94200 in addition to 94010. If you do not perform the MVV, payment is not reduced nor does it preclude the use of the 94010 CPT code.
Incentive spirometry (a measurement of sustained maximal inspiration) does not meet the AMA's definition for CPT code 94010; therefore, you cannot bill incentive spirometry with this code.
There is not a code in CPT that accurately describes the procedure of incentive spirometry.
-------------------------------------------------------------------------------
April 28, 2008
Question:
Can you provide a few billing guidelines for code 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurements(s), with or without maximal voluntary ventilation)?
Answer:
All components of the description must be ordered and performed and medically
necessary for appropriate payment by the federally funded programs. If you
do not perform the spirometry as described, you cannot use this code. If
you do everything
described plus additional parameters, then bill 94010 plus the extra tests.
-------------------------------------------------------------------------------
April 21, 2008
Question:
What are the requirements for documenting pulmonary function testing?
Answer:
Here are a few examples of requirements related to documentation of these
tests.
- Documentation supporting the medical necessity of these tests, such as
ICD-9-CM diagnosis codes, must be submitted on all claims. Claims submitted
without this information will be denied as not medically necessary.
- All providers of pulmonary function tests should have on file a referral
(a prescription) with clinical diagnoses and requested tests. Indications
for the studies should be clearly described in the clinical records and
available for review.
- All equipment and studies should meet minimum standards outlined by the
American Thoracic Society.
- Spirometry studies, in particular, require a minimum of three attempts
that must meet minimum acceptability criteria.
- All studies require an interpretation with a written report. Computerized
reports must have a physician's signature, attesting to its accuracy.
-------------------------------------------------------------------------------
April 14, 2008
Question:
Does Medicare cover long-term CPAP for patients in the home setting?
Answer:
According to the Centers for Medicare & Medicaid Services, some patients with obstructive sleep apnea (OSA) do not continue with continuous positive air pressure (CPAP) treatment or do not improve on treatment. Thus, CMS is limiting initial coverage of CPAP for OSA to 12 weeks to determine if the beneficiary will respond to the treatment. Long-term CPAP is covered for those beneficiaries who continue and respond to treatment.
-------------------------------------------------------------------------------
April 7, 2008
Question:
I believe there has been a recent change to the CPAP Medicare coverage. Can you provide a resource for this policy?
Answer:
The Centers for Medicare & Medicaid Services (CMS) did recently expand Medicare coverage for continuous positive airway pressure (CPAP) devices to include beneficiaries who have been diagnosed, using a home sleep test, with obstructive sleep apnea. CMS also announced changes to simplify certain test requirements. The final national coverage determination is available at www.cms.hhs.gov/center/coverage.asp.
-------------------------------------------------------------------------------
March 31, 2008
Question:
We know that CPR is a covered service but are not sure how many times the code may be billed per encounter. Can you provide this information?
Answer:
Cardiopulmonary resuscitation (CPR) is a covered service under the hospital outpatient prospective payment system (OPPS). The facility may bill this code one time per patient encounter. Since numerous departments respond to "code blue" situations, the facility should determine which department should submit code 92950 (CPR, as in cardiac arrest) to assure consistency in the reporting of the service. The revenue center code for this CPT code should be 480.
-------------------------------------------------------------------------------
March 24, 2008
Question:
We cannot find a code to report tests performed for respiratory syncytial virus (RSV) and influenza. Can you help?
Answer:
With the increase in "rapid screening tests" for respiratory syncytial virus (RSV) and influenza, MedLearn consultants have been receiving requests to provide CPT and billing instruction for collection of specimens via nasal lavage and suction. Unfortunately, there is no CPT or HCPCS code that represents the collection of this specimen. The cost is bundled into the CPT code that is billed for the laboratory test.
-------------------------------------------------------------------------------
March 17, 2008
Question:
I am looking for information on equipment requirements for the use of an oximeter. Can you provide any?
Answer:
Equipment requirements are defined as use of an oximeter that is preset
and self-sealed and cannot be adjusted by the patient. In addition, the
device must provide a printout that documents an adequate number of sampling
hours, percent of oxygen saturation and an aggregate of the results. A copy
of the printout must be made available for review if requested by the payer.
The equipment issued to the patient must be documented in the patient's
record, which must include documentation that the above parameters are met.
In all instances, there must be a request documented in the medical record
from the treating physician for these services.
-------------------------------------------------------------------------------
March 10, 2008
Question:
Last week you stated that Medicare may cover unattended overnight pulse oximetry procedures when performed in a facility-based sleep lab. Can you provide any billing guidelines on this?
Answer:
The following requirements summarize the information accumulated by MedLearn
consultants.
- When billing for this service, CPT code 94762 most appropriately represents
the continuous overnight oximetry trend study.
- For a limited group of payers, continuous overnight oximetry is considered
medically necessary when done for one of the following circumstances: 1)
The patient has a condition for which intermittent arterial blood gas sampling
is likely to miss important variations (e.g., sleep apnea); and 2) The patient
has a chronic condition resulting in hypoxemia, and there is a need to assess
supplemental oxygen requirements and / or a therapeutic regimen.
- Continuous overnight oximetry is considered investigational and not medically
necessary for the following: 1) As the sole diagnostic test for sleep apnea
syndrome in lieu of polysomnography or for routine screening for sleep apnea
in the absence of any of the above conditions; and 2) In the home for asthma
management.
-------------------------------------------------------------------------------
March 3, 2008
Question:
Does Medicare cover unattended pulse ox studies in a mobile facility?
Answer:
Research completed by MedLearn consultants reveals that Medicare payers do not cover unattended overnight pulse oximetry procedures carried out in the patient's home or in a mobile facility. Medicare coverage appears to be limited to attended studies performed in a facility-based sleep study laboratory. Coverage of the unattended study appears to be limited to those procedures billed by the independent diagnostic testing facility (IDFT) to the durable medical equipment regional carrier (DMERC).
-------------------------------------------------------------------------------
February 25, 2008
Question:
I would like to know if, when we bill spirometry (94010), may we also bill A4617 for the disposable mouthpiece? Or would this be considered part of the spirometry charge?
Answer:
When billing spirometry, the code A4617 would not be reported separately. Bundle the cost of the mouthpiece into the total charge for the diagnostic test.
-------------------------------------------------------------------------------
February 18, 2008
Question:
Is it appropriate to report 94002 in the hospital ED?
Answer:
The CPT 94002 (ventilation assist and management, initial day) by definition is excluded from being reportable for services provided in the emergency department. However, there are two procedure codes in the 94XXX series where this restriction is not so clear. CPT codes 94660 (continuous positive airway pressure [CPAP] ventilation, initiation and management) and 94662 (continuous negative pressure ventilation [CNP], ventilation and management) do not include reference as to the setting in which the service is or is not billable. However, the CPT codes are specifically excluded from reporting when CPAP, BiPAP or CNP are applied during critical care levels of service in the ED. Refer to the reporting guidelines for 99291 (critical care, evaluation and management) in the CPT code book.
-------------------------------------------------------------------------------
February 11, 2008
Question:
Does Medicare cover portable multi-channel sleep-study testing when it is unattended?
Answer:
Effective April 4, 2005, the Centers for Medicare & Medicaid Services determined that there is not sufficient evidence to conclude that unattended portable multi-channel sleep study testing is reasonable and necessary in the diagnosis of obstructive sleep apnea (OSA) for continuous positive airway pressure (CPAP) therapy. These tests will remain noncovered for this purpose. This information and more about can be found in Section 240 of Medicare's National Coverage Determinations Manual.
-------------------------------------------------------------------------------
February 4, 2008
Question:
What chargemaster guidelines can you provide in regard to the new smoking cessation codes?
Answer:
Hospital departments that have previously billed for counseling visits must update the code assignment on the chargemaster replacing G0375 with CPT 99406 for sessions lasting between three and 10 minutes. Code 99407 will replace G0376 when reporting counseling sessions lasting more than 10 minutes. The codes do not represent billable increments of time and are not reported as "add-on" codes - report only one CPT per encounter. Regardless of the coding revisions, the reimbursement under OPPS remains relatively the same (approximately $10.50 per encounter).
-------------------------------------------------------------------------------
January 28, 2008
Question:
Does Medicare cover IPV?
Answer:
No coverage is available for an intrapulmonary percussive ventilator (IPV), according to section 240.5 of Medicare' National Coverage Determination Manual. According to the Centers for Medicare & Medicaid Services, studies do not demonstrate any advantage of IPV over that achieved with good pulmonary care in the hospital environment. Also, says CMS, there are no data to support the effectiveness of the device in the home setting, so IPV also is not covered there.
-------------------------------------------------------------------------------
January 21, 2008
Question:
Can you provide information on assigning the new codes for smoking cessation counseling?
Answer:
The American Medical Association added the following codes to the preventive
medicine subsection that can be used to report face-to-face smoking and
tobacco use cessation counseling. These codes replace the two temporary
HCPCS codes G0375 and G0376.
99406 Smoking and tobacco-use cessation counseling visit; intermediate,
greater than 3 minutes up to 10 minutes
99407 Smoking and tobacco-use cessation counseling visit; intensive, greater
than 10 minutes
The codes do not represent billable increments of time and are not reported as "add-on" codes; report only one CPT per encounter. Regardless of the coding revisions, the reimbursement under OPPS remains relatively the same (i.e., approximately $10.50 per encounter).
Counseling services lasting three minutes or less continue to be a bundled service, not separately billable. This limited intervention is considered an integral part of the interaction with patients presenting to the respiratory therapy department and/or the pulmonary rehabilitation unit.
-------------------------------------------------------------------------------
January 14, 2008
Question:
Does Medicare cover nebulized beta adrenergic agonist therapy?
Answer:
Effective September 10, 2007, there is no national coverage determination (NCD) for nebulized beta adrenergic agonist therapy for lung diseases. According to the Centers for Medicare & Medicaid Services, national coverage is not "appropriate." Billing staffs should be made aware that Medicare contractors will continue to make reasonable-and-necessary decisions through their local coverage determinations or case-by-case adjudication.
-------------------------------------------------------------------------------
January 7, 2008
Question:
Our respiratory care department staff sometimes educates family or caregivers about the use and maintenance of the apnea monitor and overall management of an infant's care. What code should be assigned for this?
Answer:
The CPT code selection does not define such training or equipment-use demonstration. Only the entity that provides the monitor attachment and/or download of information may bill from CPT codes 94774-94777.
-------------------------------------------------------------------------------
December 31, 2007
Question:
Which codes cannot be reported with new CPT code 32422 (thoracentesis with insertion of tube)?
Answer:
Do not report 32422 with 19260, 19271, 19272, 32503, 32504, according to the 2008 CPT manual.
-------------------------------------------------------------------------------
December 24, 2007
Question:
Are there any billing guidelines available yet on what imaging codes can be assigned with 2008 code 32421 (thoracentesis)?
Answer:
According to the 2008 CPT manual, if imaging guidance is performed, see
the following codes:
76942 -- Ultrasonic guidance for needle placement
77002 -- Fluoroscopic guidance for needle placement
77012 -- Computed tomography guidance for needle placement
-------------------------------------------------------------------------------
December 17, 2007
Question:
You mentioned last week that two codes were added for thoracentesis. Can you provide the codes and descriptions?
Answer:
The following codes have been added under the "removal" subsection
of Lungs and Pleura:
32421 - Thoracentesis, puncture of pleural cavity for aspiration, initial
or subsequent
32422 - Thoracentesis with insertion of tube, includes water seal (e.g.,
for pneumothorax) when performed (separate procedure)
All CPT code changes take effect on January 1, 2008.
-------------------------------------------------------------------------------
December 10, 2007
Question:
For 2008, what kind of CPT changes did the AMA make to the respiratory section of surgery?
Answer:
Under the Lungs and Pleura, Incision subsection, five codes (32000-32020) were deleted. Of the five code additions, two relate to removals, two to introductions, and one to destruction. All CPT code changes take effect on January 1, 2008.
-------------------------------------------------------------------------------
December 3, 2007
Question:
I have a question related to the answer you gave on November 12 post related to pulse oximetry performed for outpatients. You said that, services such as 94760 must be reported in combination with a significant procedure when billing Medicare. Does routine monitoring fall into this rule?
Answer:
The Centers for Medicare & Medicaid Services (CMS) always encourages facilities to accurately bill for medically necessary pulse oximetry. In all instances, there must be a documented request in the medical record by a physician or practitioner. Parameters for each measurement should be included in the request. In all circumstances, testing would be expected to be useful in the continued management of a patient's care particularly in acute exacerbations or unstable conditions (e.g., acute bronchitis in a patient with COPD). Use of pulse oximetry for routine monitoring of the patient does not meet the Medicare requirements for "reasonable and necessary" and should not be billed.
-------------------------------------------------------------------------------
November 26, 2007
Question:
To bill for patients who routinely use devices for home treatments, can we assign code 94664 (demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device)?
Answer:
Do not bill this CPT code for patients who routinely use the devices to provide treatments at home unless there are unusual circumstances. The documentation in the patient's medical record should provide the rationale for providing the patient education related to bronchodilator administration and include comments about the patient's ability to correctly use the delivery device. Also, do not bill separately for the breathing treatment that is administered at the time the evaluation or demonstration of the device is provided.
-------------------------------------------------------------------------------
November 19, 2007
Question:
Is it appropriate to submit a claim that includes code 94200 with 94060?
Answer:
Code 94200-maximum breathing capacity, maximal voluntary ventilation (MVV) -is considered a component of the following codes: 94010, 94060 or 94070. Billing 94200 on the same date of service (DOS) as one of the preceding codes is considered double billing and will result in a denial. However, if a MVV is performed separately on the same DOS as another MVV or a spirometry, be sure to append modifier 59 (distinct procedural service).
-------------------------------------------------------------------------------
November 12, 2007
Question:
Is separate payment available under Medicare for pulse oximetry performed for outpatients?
Answer:
Under the outpatient prospective payment system (OPPS), codes 94760 (pulse oximetry; single determination) and 94761 (pulse oximetry; multiple determination) are classified as incidental or packaged services. When reporting to Medicare, these services must be reported in combination with a significant procedure. While it is appropriate to bill for incidental services, Medicare will pay no additional reimbursement.
-------------------------------------------------------------------------------
November 5, 2007
Question:
What revenue codes should be assigned for respiratory therapy and pulmonary function codes?
Answer:
For respiratory therapy codes (94640-94668), assign revenue code 410. For pulmonary function codes (94010-94621, 94680-94772), assign revenue code 460.
-------------------------------------------------------------------------------
October 29, 2007
Question:
Please provide some guidelines related to receiving optimal reimbursement for respiratory services but staying in compliance with the law.
Answer:
Receiving correct reimbursement while maintaining regulatory compliance
for respiratory therapy and pulmonary function studies requires adherence
to the following concepts:
- Complete documentation of services rendered
- Accurate code assignment (CPT, HCPCS, revenue)
- Valid charge-capture procedures
- Logical fee structures
- Efficient data-collection and information regarding processes
- Effective billing and reporting procedures
-------------------------------------------------------------------------------
October 22, 2007
Question:
Editor's Note: Our respiratory Q&A posted October 8 prompted the following questions. This week's answer will hopefully clarify the confusion caused by the previous answer. We apologize for any inconvenience the previous answer may have caused.
In one of your recent respiratory questions and answers, you seemed to indicate that inpatient BiPap should be billed as continuous ventilation instead of CPAP. Did I understand this correctly? Also, could you please advise us on which code is correct to use for inpatient BiPAP initiation and management?
Answer:
BiPAP-a noninvasive method of ventilatory support-includes continuous
positive airway pressure (CPAP) and pressure support ventilation. BiPAP
does not have a separate code in CPT, because it is a component of CPAP.
For BiPAP, the American Medical Association (AMA) instructs providers to
use code 94660-CPAP ventilation, initiation and management.
Medically necessary application of BiPAP that has been ordered by the treating
physician is billable both in the outpatient setting and inpatient setting.
CPT code 94660 may be used for the initiation and subsequent management
of CPAP or BiPAP. Services are billed per day, not per hour, for both procedures.
However, payment for the inpatient services will be included within the
MS-DRG payment received by the hospital. BiPAP is used as an alternative
to invasive ventilator management which, beginning January 1, 2007, is represented
by the following CPT codes in the hospital setting.
94002 Ventilation assist and management, initiation of pressure or volume
preset ventilators for assisted or controlled breathing; hospital inpatient/observation,
initial day
94003 hospital inpatient/observation, each subsequent day
-------------------------------------------------------------------------------
October 15, 2007
Question:
My question relates to patients with new onsets of respiratory distress. When we provide a nebulizer treatment and usage instructions to them, should we assign 94640 or 94664?
Answer:
If the treatment and education happen concurrently, we would recommend billing only 94664-demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device. The treatment is bundled to the demonstration and evaluation.
The two codes would be separately billable if a treatment is provided to relieve an acute airway, and it is followed by a separate demonstration providing the patient with instruction on how to deliver therapy. The separate services must be clearly documented at different times.
-------------------------------------------------------------------------------
October 8, 2007
Question:
What CPT code should be used for BiPAP reimbursement? Is there a difference between continuous positive airway pressure and BiPAP coding? Also, is there a difference between CPT coding of the home BiPAP unit and noninvasive BiPAP in the hospital setting?
Answer:
In the outpatient setting only, the following CPT code is used for CPAP.
This code includes BiPAP. In the inpatient setting, no code may be billed
because it is considered part of ventilator management.
- 94660 CPAP, initiation and management
-------------------------------------------------------------------------------
October 1, 2007
Question:
Does Medicare cover nebulized beta adrenergic agonist therapy?
Answer:
In late 2006, the Centers for Medicare & Medicaid Services (CMS) initiated a national coverage determination (NCD) analysis for nebulized beta adrenergic agonist therapy for lung diseases. After examining the available medical evidence, it determined that no NCD is appropriate at this time, and the decision should be made by local contractors through local coverage determinations or by case-by-case adjudication.
The decision memo and discussion about this topic (CAG-00354N) can be found at https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=198.
-------------------------------------------------------------------------------
September 24, 2007
Question:
Can respiratory therapists (RTs) who work in a comprehensive outpatient rehabilitation facility (CORF) receive separate payment?
Answer:
Medicare legislation doesn't recognize respiratory therapists (RTs) as independent practitioners. Also, RT services do not have a statutory benefit category except as specified in the CORF services benefit at section 1861(cc)(1)(B) of the Social Security Act. Therefore, separate payment is not made for services provided by RTs. Instead, they are most often employed in physician offices and in facility settings, such as hospitals and skilled nursing facilities, where payment is made to the RT employer.
-------------------------------------------------------------------------------
September 17, 2007
Question:
What is the most common billing error your consultants encounter in the respiratory therapy (RT) department?
Answer:
RT department managers attempt to build in charge description master line items that represent time-based services such as specimen collection, patient transport, or patient training and education. However, all of this time is considered inherent in the operation of an RT department and is calculated into administrative cost.
-------------------------------------------------------------------------------
September 10, 2007
Question:
I am the director of a hospital respiratory care department. I am looking for information about the nasal lavage and suctioning into a Lukins for RSV. Can you provide information and a charge code?
Answer:
There is no procedure code for the specimen collection. You need to focus on the time the technician spends collecting the specimen, which is subsequently sent to the laboratory for testing.
As you know, most staff time is spent providing non-billable services and supporting other departments such as nursing. MedLearn recommends separating the calculation of staffing from financial / billing statistics. Evaluate each procedure or service for acuity, resource and time, and base staffing on requirements to assure proper patient care similar to the criteria for nursing staff.
-------------------------------------------------------------------------------
September 3, 2007
Question:
In addition to reconsidering its national coverage determination (NCD) for obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy, do you know whether CMS intends to change any other related Medicare policies?
Answer:
In December 2006, the Centers for Medicare & Medicaid Services (CMS) internally generated a formal request for a national coverage analysis to determine when treatment with a nebulized beta adrenergic agonist is reasonable and necessary for Medicare beneficiaries with chronic obstructive pulmonary disease (COPD). On its web site, CMS state that it "has become aware of concerns regarding the appropriate use of nebulized beta adrenergic agonist therapy for lung diseases." A proposed decision was due in June 2007 but has not yet appeared.
-------------------------------------------------------------------------------
August 27, 2007
Question:
Last week you mentioned that CMS was reviewing its national coverage determination on obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy. Can you provide more details, including a web site link to this information?
Answer:
In March, 2007, the Centers for Medicare & Medicaid Services (CMS) received a complete formal written request from the American Academy of Otolaryngology-Head and Neck Surgery to modify this decision to include the use of portable multi-channel home sleep-testing devices as an alternative to facility-based polysomnography in the evaluation of OSA. According to the CMS web site, it expects to issue a proposed decision memo in December 2007. For more, go to http://www.cms.hhs.gov/mcd/index_list.asp?list_type=nca.
-------------------------------------------------------------------------------
August 20, 2007
Question:
I have heard differing versions of the Medicare coverage policy for CPAP. Can you provide any definitive information?
Answer:
The Centers for Medicare & Medicaid Services is reviewing its national coverage determination (NCD) regarding the diagnosis of patients with obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy. However, current national coverage policy specifies that only polysomnography done in a facility-based sleep study laboratory can be used to identify patients with OSA requiring CPAP.
-------------------------------------------------------------------------------
August 13, 2007
Question:
Does the purchased diagnostic test arrangement apply to the technical or professional component of global sleep studies?
Answer:
In its guidelines the Centers for Medicare & Medicaid Services indicates that, for purchased interpretations, the test must be initiated by a physician or medical group independent of both parties providing the components of the tests. Also, if the interpreting provider bills his/her own interpretation, it is no longer a "purchased" interpretation. The concept of purchased diagnostic test is that the purchaser bills Part B for the purchased component. There are claim requirements to indicate a component of the test was purchased, the purchaser cannot bill a global code, rather each component on a separate line with TC/26 modifiers.
-------------------------------------------------------------------------------
August 6, 2007
Question:
Can patient training and education provided by the respiratory therapist be billed?
Answer:
Many people struggle with statistics for staffing rather than billing for services. RT is unlike many of the other ancillary departments because most of their time is spent providing non-billable services and supporting other departments such as nursing. We recommend separating the calculation of staffing from financial / billing statistics. Because most of the time spent providing RT support services is non-billable, each procedure or service should be evaluated for acuity, resource and time. Staffing should be based on requirements to assure proper patient care similar to the criteria for nursing staff.
The most common billing error we encounter during chargemaster reviews is when RT department managers attempt to build chargemaster line items that represent time-based services such as specimen collection, patient transport, or patient training and education. All of this time is considered inherent in the operation of an RT department and is calculated into administrative cost.
-------------------------------------------------------------------------------
July 30, 2007
Question:
What must physicians do to ensure medical necessity for sleep studies?
Answer:
According to many reimbursement experts, physicians often order a sleep study without performing the needed diagnostic tests to establish that it is, indeed, reasonable and necessary. One way to ensure that medical necessity has been met is for the primary care physician to complete a preliminary assessment on the patient, such as the sleepiness scale--a simple evaluation to find out how likely a person is to fall asleep in a variety of situations.
Another way to ensure medical necessity is for the patient's primary care physician to request an overnight pulse oximetry test (CPT code 94762). The findings from this procedure will help determine the necessity for a sleep study.
Any and all diagnostic test orders must, of course, be supported by an appropriate ICD-9-CM diagnosis code.
To avoid having to write off services that are determined not to be medically necessary (per national or local policies), providers should issue an advance beneficiary notice (ABN) to patients. With an ABN, providers inform patients up front that Medicare does not consider the procedure to be medically necessary.
-------------------------------------------------------------------------------
July 23, 2007
Question:
Can ventilator management care plan oversight be reported separately from home, domiciliary, or rest home services?
Answer:
If you are assigning new (for 2007) CPT code 94005, you may report the
service separately. The 2007 CPT code manual gives the following guidelines
for this code:
- Do not report 94005 in conjunction with 99339-99340, 99374-99378.
- A physician may report 94005, when performed, including when a different
physician reports 99339-99340, 99374-99378 for the same 30 days.
-------------------------------------------------------------------------------
July 16, 2007
Question:
What is the most common reason that hospitals aren't reimbursed for sleep studies?
Answer:
The most common reason is the lack of medical necessity. Here are two tips to comply with Medicare's medical necessity requirements:
- Ensure that all physician documentation is comprehensive and supports
medical necessity. The referring practitioner, for example, must provide
documentation of the signs, symptoms, or diagnosis.
- Pay close attention to a procedure's frequency limitations for coverage,
which may be available from your FI or from CMS.
These limitation frequencies may be difficult to monitor because they are
beneficiary-specific, not provider-specific. This means that the testing
facility is always at risk, because staff members do not know if the procedure
was performed at another facility within the defined time frame.
-------------------------------------------------------------------------------
July 9, 2007
Question:
I am looking for guidance on assigning code 31622. Can you provide any billing tips?
Answer:
Code 31622 describes a rigid or flexible bronchoscopy performed with or without fluoroscopic guidance. It is used for diagnostic purpose with or without saline washing for collection of culture or cytologic specimens. The 2007 CPT manual lists it as a separate procedure.
If the operative report states that a bronchoscope was used to evaluate the tracheobronchial tree and that sterile saline washings were recovered and sent for culture and/or cytologic examination, it is correct to assign 31622.
-------------------------------------------------------------------------------
July 2, 2007
Question:
We had a patient admitted with acute respiratory failure who was placed on ventilator management. What would be the correct code for the following scenario?
Answer:
For the initial day, CPT code 94002 is correct. Note that you should not
report this code along with a code from the evaluation and management range
of 99201-99499.
In CPT Assistant (March 2007), the American Medical Association states
the following: The intraservice period includes the services provided by
the physician while he/she is present on the patient hospital unit or floor.
This includes revising the chart, seeing t he patient, writing notes, and
communicating with other healthcare professional and the patient's family
or caregiver.
-------------------------------------------------------------------------------
June 25, 2007
Question:
I am billing code 32002 for a thoracentesis with tube insertion. What codes should be used if imaging guidance is performed?
Answer:
This, of course, depends on the type of imaging. The 2007 CPT manual indicates that the coder should see the following radiology codes: 76942, 77002, 77012.
-------------------------------------------------------------------------------
June 18, 2007
Question:
When an imaging procedure is performed with a pleura biopsy (CPT code 32400), what code should be reported?
Answer:
According to the 2007 CPT manual, the following codes should be consulted. In the ultrasound subsection of the radiology section, check 76942. Under fluoroscopic guidance, check code 77002. Under computed tomography guidance, check 77012. And, finally, under magnetic resonance guidance, check 77021.
-------------------------------------------------------------------------------
June 11, 2007
Question:
The Medicare coding and coverage policies related to pulmonary rehab are confusing. Can you provide any insight into these?
Answer:
The three HCPCS Level II codes below may be used to report outpatient
pulmonary rehabilitation services provided by the respiratory therapist.
The services are paid under the "incident-to physician services"
provision for hospital outpatients.
G0237--Therapeutic procedures to increase strength or endurance of respiratory
muscles, face-to-face, one-on-one, each 15 minutes (includes monitoring)
G0238--Therapeutic procedures to improve respiratory function, other than
ones described in G0237, one-on-one, face-to-face, per 15 minutes (includes
monitoring)
G0239--Therapeutic procedures to improve respiratory function, other than
services described by G0237, two or more
The best way to be in compliance with pulmonary rehabilitation program billing is to check with your Medicare payer to confirm that there is a current coverage determination for your state. Look for its local coverage determination (LCD), which contains billing guidelines plus other information that will help you avoid situations in which claims are paid or denied without may not be covered by Medicare.
-------------------------------------------------------------------------------
June 4, 2007
Question:
In addition to respiratory therapists, what other healthcare personnel are allowed to perform respiratory services?
Answer:
Respiratory services may be performed by qualified respiratory therapists
(RT) (as defined by national and state regulations), RT technicians, or
qualified nursing personnel. A "qualified" individual is one who
has completed an educational or training program and has documented evidence
of the ability to perform respiratory care interventions and modalities.
There may be overlaps of skills between respiratory and nursing services.
In these instances, there must be specific documentation to support the
need for interventions by a qualified RT. Documentation in the medical record
must clearly support the need for the specific skills of the RT to be separately
reimbursed.
Many Medicare payers have addressed the services they consider to be covered,
including who can perform them, in their local coverage determinations (LCDs).
Check with your local payer to determine requirements for your facility.
-------------------------------------------------------------------------------
May 28, 2007
Question:
What is the maximum number of times that a facility may bill CPR?
Answer:
Cardiopulmonary resuscitation (CPR) is a covered service under the hospital outpatient prospective payment system (OPPS). Facilities may bill this code one time per patient encounter. Since numerous departments respond to "code blue" situations, the facility should determine which department should submit the code to assure consistency in the reporting of the service.
-------------------------------------------------------------------------------
May 21, 2007
Question:
Can you provide some billing guidelines for using code 94010--spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurements(s), with or without maximal voluntary ventilation?
Answer:
All components of the description must be ordered and performed and medically necessary for appropriate payment by the federally funded programs. If you do not perform the spirometry as described, you cannot use this code. If you do everything described plus additional parameters, then bill 94010 plus the extra tests.
-------------------------------------------------------------------------------
May 14, 2007
Question:
Does Medicare pay for a total vital capacity under code 94150?
Answer:
CMS pays CPT code 94150 as an ancillary service under the hospital outpatient prospective payment system. Many facilities have this code assigned to line items described as "peak flow."
In the 2001 CPT Companion, the American Medical Association stated that there is not a separate listing in CPT for reporting peak flow. The Principles of CPT Coding manual published by the American Medical Association in 1999 states, "There is no separate code in CPT for reporting the performance of peak flow rate measurement. When performed, peak flow rate is an inherent part of the evaluation and management examination and is not separately reported."
If you have defined this code on your chargemaster as peak flow, consider inactivating the line item or remove the CPT code and track the procedure for "statistics only." The peak flow meter is considered a routine supply that should be bundled into the cost of the procedure.
-------------------------------------------------------------------------------
May 7, 2007
Question:
What codes should be assigned to Medicare for a mask that is used with continuous positive airway pressure device (CPAP)?
Answer:
Effective July 1, 2007, the Centers for Medicare & Medicaid Services
established three new "K" codes for oral/mask for use with CPAP.
Medicare payers will add the following codes to their systems.
K0553 -- Combination oral/nasal mask, used with continuous positive airway
pressure device, each
K0554 -- Oral cushion for combination oral/nasal mask, replacement only,
each
K0555 -- Nasal pillows for combination oral/nasal mask, replacement only,
pair
For the transmittal announcing this policy, go to http://www.cms.hhs.gov/transmittals/downloads/R1210CP.pdf.
-------------------------------------------------------------------------------
April 30, 2007
Question:
Where can I find information about maintaining and servicing capped rentals and oxygen equipment?
Answer:
In provider-information memo MM5461, CMS summarizes its policy for suppliers of oxygen equipment and services. This memo, along with Transmittal 1177 (issued February 2, 2007, address changes in Medicare processes impacting maintenance and servicing of oxygen equipment for Medicare beneficiaries. These changes take effect on July 2, 2007, although the effective date is January 1, 2006. For this information, see http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5461.pdf.
-------------------------------------------------------------------------------
April 23, 2007
Question:
Is it appropriate to an expired gas collection collection in addition to any of the respiratory therapy codes?
Answer:
Billing for the expired gas collection in addition to any of the respiratory therapy codes-94620, 94621, 94680 and 94681 as included in the CCI edits will result in double billing-and a claim denial. To report a determination for expired nitric oxide, refer to the CPT code 95012 introduced by the AMA in 2007.
-------------------------------------------------------------------------------
April 16, 2007
Question:
Does Medicare still consider patient-initiated spirometric recordings to be an experimental test?
Answer:
CPT codes 94014, 94015, and 94016 are generally considered not covered by Medicare since their clinical efficacy has not been established. Many states have coverage policies for patient initiated spirometric recording. Check with your Medicare fiscal intermediary or carrier for coverage polices relevant to your facility.
-------------------------------------------------------------------------------
April 9, 2007
Question:
What kind of documentation does Medicare require for pulmonary function tests?
Answer:
Documentation supporting the medical necessity of these tests, such as ICD-9-CM diagnosis codes, must be submitted on all claims. Claims submitted without this information will be denied as not medically necessary.
All providers of pulmonary function tests should have on file a referral
(a prescription) with clinical diagnoses and requested tests. Indications
for the studies should
be clearly described in the clinical records and available for review. In
addition:
- All equipment and studies should meet minimum standards outlined by the
American Thoracic Society.
- Spirometry studies, in particular, require a minimum of three attempts
that must meet minimum acceptability criteria.
- All studies require an interpretation, with a written report. Computerized
reports must have a physician's signature, attesting to its accuracy.
-------------------------------------------------------------------------------
April 2, 2007
Question:
Can hospitals charge E&M codes for respiratory therapy services?
Answer:
The cost for patient evaluation and management by respiratory therapists is calculated into the charge for therapeutic or diagnostic procedures billed by the department. With the exception of the procedures included in CPT 94664, it is not appropriate to generate a separate charge for evaluation and management of the patient or for patient assessment and education. Respiratory therapy departments do not typically have the need for CPT codes 99201-99215 to be included as billable items on the department chargemaster.
-------------------------------------------------------------------------------
March 26, 2007
Question:
Is there any difference between a sleep study and polysomnography?
Answer:
According to the CPT manual, polysomnography is distinguished from sleep studies by the inclusion of sleep staging, which is defined to include an electroencephalogram (EEG) with one to four leads, an electro-oculogram (EOG), and a submental electromyogram (EMG). (Note that PSG requires at least one central and usually several EEG electrodes. The EEG used during PSG differs from that performed for separate diagnostic purposes.)
These electrophysiological (EP) procedures record a variety of body functions during sleep, including electrical activity of the brain, eye movement, muscle activity, heart rate, breathing, airflow through the nose and mouth, and blood oxygen levels. The CPT manual provides a long list of additional parameters for sleep tests and notes that there may be others.
-------------------------------------------------------------------------------
March 19, 2007
Question:
Are sleep labs reimbursed separately for patient evaluations?
Answer:
In the setting of a hospital-based sleep laboratory, a separate charge is typically not indicated for an evaluation and management (E&M) code. However, the reporting guidelines for E&M codes may vary for the physician office setting, freestanding sleep laboratory, and independent diagnostic testing facility. Be sure to review the guidelines that apply to your setting and bill accordingly.
-------------------------------------------------------------------------------
March 12, 2007
Question:
Does Medicare cover heat treatment for pulmonary conditions?
Answer:
According to Section 240.3 of the National Coverage Determinations Manual, the answer is no. In that section, the Centers for Medicare & Medicaid Services states the following: "There is no physiological rationale or valid scientific documentation of effectiveness of diathermy or ultrasound heat treatments for asthma, bronchitis, or any other pulmonary condition and for such purpose this treatment cannot be considered reasonable and necessary..."
-------------------------------------------------------------------------------
March 5, 2007
Question:
In regard to billing for codes 94644 and 94645, can you provide any direction about how to bill for the time involved?
Answer:
The following CPT codes represent hourly charges for delivery of therapy: 94644--continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour-and 94645--each additional hour (List separately in addition to code for primary procedure). The initial-hour code-94644-includes set-up time, device/supplies and medication. Each additional hour of therapy is represented by CPT code 94645.
Because pulse oximetry is used as a monitor rather than as a diagnostic
tool there is no charge generated for 90760 or 90761. There are no additional
charges generated
for time spent in attendance by the respiratory care therapist or monitoring
of the patient.
Each CPT time-based code is structured to reflect the procedure or service as performed in current clinical practice. Some codes in CPT use the term "up to 1 hour" indicating that the code is reportable for any time increment up to 60 minutes (e.g. 30 minutes, 45 minutes, 60 minutes). However, CPT code 94644 uses the term "first hour," which restricts its use to only procedures lasting 60 minutes. An AMA communication to MedLearn in January 2007 stated that the 60-minute increment of time also applies to the add-on code 94645.
-------------------------------------------------------------------------------
February 26, 2007
Question:
I am looking for guidance on reporting codes 94644 and 94645. Specifically, can 94645 be assigned with 94644?
Answer:
According to a communication to MedLearn from the American Medical Association, 60 minutes of treatment must be performed to qualify for reporting code 94644. Sixty minutes of additional treatment must be performed to report add-on code 94645 in addition to code 94644.
As indicated in the parenthetical note following 94644, if the service is performed for less than one hour, code 94640 is reported. For less than one hour of treatment, neither code 94644 or 94645 is reported. Code 94640 describes a treatment administered several times a day at short intervals (e.g., 1 0 minutes), whereas continuous inhalation treatment (94644, 94645) is administered for longer periods and then discontinued. A higher dosage of medication and different equipment are used.
-------------------------------------------------------------------------------
February 19, 2007
Question:
My billing office tells me that when billing for inpatient stays in our
hospital that CPT 94660 with modifier 76 isn't necessary for nebulizer treatments
unless it is an outpatient service. I'm confused about what they're saying.
Can you clarify?
Answer:
On an inpatient bill, charged services combine on one line item for each
revenue code that has been used to charge the patient. (For respiratory
care, the revenue code is 410 for treatment and 460 for diagnostic services).
Therefore, the CPT codes do not show on an inpatient bill. On an outpatient
bill, the services are billed and reimbursed under APCs, which are based
on CPT codes. Therefore, the CPT codes must show on line item billing as
opposed to combining on one line item without CPT codes. The modifiers are
ways of informing the payers that you did not accidentally double bill them.
-------------------------------------------------------------------------------
February 12, 2007
Question:
What kind of documentation is required for pulmonary function tests?
Answer:
All providers should have a referral (a prescription) with clinical diagnoses
and requested tests. Indications for the studies should be clearly described
in the clinical records and available for review.
-------------------------------------------------------------------------------
February 5, 2007
Question:
Does Medicare have any coverage policy related to use of nebulized beta
adrenergic agonist for chronic obstructive pulmonary disease?
Answer:
According to the Medicare coverage database, in late December 2006, the
Centers for Medicare & Medicaid Services (CMS) internally generated
a formal request for a national coverage analysis to determine when treatment
with a nebulized beta adrenergic agonist is reasonable and necessary for
Medicare beneficiaries with COPD. On the tracking sheet for this NCA, CMS
stated that it has become aware of concerns regarding the appropriate use
of nebulized beta adrenergic agonist therapy for lung diseases. For other
details about the NCA, go to https://www4.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=198
--------------------------------------------------------------------------------
January 29 , 2007
Question:
Does Medicare pay for code 94762?
Answer:
Under the previous outpatient prospective payment system (OPPS) restrictions
when a packaged service was the only procedure appearing on a claim, it
would not pass the Medicare claims edits. This resulted in services being
provided that couldn't be billed. As a result of public requests, the Centers
for Medicare & Medicaid Services formed a special ambulatory payment
classification (APC) subcommittee to consider payment options for packaged
services that are commonly provided alone.
In 2007, CMS introduced a new category for incidental procedures called
"special packaged service" and assigned new status indicator Q
to them. There are now six CPT codes listed in this category including 94762
(continuous overnight pulse oximetry). Beginning January 1, 2007, if 94762
is the only OPPS procedure provided on a given date of service the hospital
may bill and be reimbursed for this service.
--------------------------------------------------------------------------------
January 22, 2007
Question:
In your respiratory Q&A last week, you mentioned that codes 94760 and
94761 are not separately reimbursed. Does this mean that we should not bill
them at all?
Answer:
This by no means indicates that the procedure should not be billed. Since
the implementation of the OPPS, the Centers for Medicare & Medicaid
Services (CMS) has encouraged facilities to accurately bill for medically
necessary pulse oximetry. The key term is "medically necessary."
In all instances, there must be a documented request in the medical record
by a physician or practitioner. Parameters for each measurement should be
included in the request. In all circumstances, testing would be expected
to be useful in the continued management of a patient's care particularly
in acute exacerbations or unstable conditions (e.g., acute bronchitis in
a patient with COPD). Use of pulse oximetry for routine monitoring of the
patient does not meet the Medicare requirements for "reasonable and
necessary" and should not be billed.
--------------------------------------------------------------------------------
January 15, 2007
Question:
Does Medicare pay separately for codes 94760 and 94761?
Answer:
Under the hospital outpatient prospective payment system, the following
codes are assigned to status indicator “N,” which means that they
are incidental services and not separately reimbursed:
- 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single
determination
- 94761 Noninvasive ear or pulse oximetry for oxygen saturation; multiple
determinations (e.g., during exercise)
--------------------------------------------------------------------------------
January 8, 2007
Question:
How has payment for capped rental items changed since implementation of
the Deficit Reduction Act?
Answer:
Under the payment methodology in effect before the DRA, Medicare paid for
certain types of durable medical equipment (DME) under a capped rental arrangement,
which allowed a beneficiary to either purchase the equipment after 13 continuous
months or continually rent the equipment from the supplier. If the beneficiary
continued to rent the equipment from the supplier, Medicare made two additional
monthly payments and a semi-annual maintenance and servicing payment even
if no services were furnished. Beneficiaries were responsible for a 20 percent
payment equal to 20 percent of Medicare's allowed monthly rental payment
amount for the equipment.
The DRA revised Medicare payments for capped rental items to 13 continuous
months only. The DRA required that the supplier transfer ownership for the
capped rental equipment to the beneficiary after the 13th continuous month
of rental. This provision applies for capped rental items for which the
first rental month occurs on or after January 1, 2006. A supplier must offer
beneficiaries the opportunity to purchase a power-driven wheelchair at the
time that the supplier furnishes the item.
--------------------------------------------------------------------------------
January 1, 2007
Question:
Did the payment method for oxygen equipment improve as a result of the DRA?
Answer:
Effective January 1, 2006, section 5101(b) of the DRA of 2005 amended the
Social Security Act limiting the total number of Medicare payments for oxygen
equipment to 36 continuous months. After 36 continuous months of rental,
the DRA requires that ownership for the stationary and/or portable oxygen
equipment must be transferred from the supplier to the beneficiary.
In the case of the beneficiaries using oxygen equipment on December 31, 2005, the 36-month rental period begins on January 1, 2006. The DRA also required that Medicare continue to make payments for delivery and refilling of oxygen contents for beneficiary owned gaseous or liquid systems for as long as it is medically necessary.
Before passage of the DRA, Medicare made continuous monthly payments for
those beneficiaries who use oxygen equipment as long as it was medically
necessary. Beneficiaries were responsible for a 20 percent coinsurance of
Medicare's payment on the rental of the equipment. As a result, a beneficiary's
coinsurance payment would often exceed the purchase price of the oxygen
equipment without the beneficiary acquiring title to the equipment.