Respiratory Compliance Question of the Week
Archive
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August 30, 2010
Question:
My question relates to CPT code 31623 (rigid bronchoscopy with brushings). How many times can this code be assigned?
Answer:
For brushings or protected brushings, use code 31623 once, regardless of the number of passes of the brush are required. The ICD-9-CM coding system used for reporting of inpatient procedures considers bronchoscopy with brushings and washings as a biopsy. Be careful of the differences in coding for inpatient and outpatient procedures and assure that the procedure is accurately reported.
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August 23, 2010
Question:
What special coverage conditions exist for postural drainage procedures and pulmonary exercise?
Answer:
The Medicare national coverage determination (NCD) for postural drainage procedures and pulmonary exercise states that in most cases the procedures can be safely and effectively provided by nursing personnel.
However, where the clinical condition of the patient requires the knowledge and skills of a physical therapist or respiratory therapist (RT), the physician must specify the procedures to be performed by the therapist in his or her plan of treatment. When the attending physician indicates the need for services to be provided by the RT, the services are covered when provided as inpatient and outpatient hospital services. This service is not covered when provided by a RT under the home health benefit.
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August 16, 2010
Question:
Can codes 94667 and 94668 be assigned when a therapist performs routine turning and repositioning of patients?
Answer:
Routine turning or re-positioning of the patient does not require the skill of a trained respiratory therapist as patients may be instructed to turn themselves, or they may be turned by a caregiver or positioned by a special device or bed. Routine turning and re-positioning of the patient do not meet the definition of CPT code 94667 or 94668, according to definitions provided in the American Association for Respiratory Care’s clinical guidelines.
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August 9, 2010
Question:
Can Respiratory departments bill for Intubation and CPR if the procedure is performed by a credentialed Respiratory Care Practitioner and in their states Liscensure act?
Answer:
Yes, this is a billable service.
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August 2, 2010
Question:
What codes should SNFs report for ventilation management?
Answer:
There are two codes that represent services provided in the skilled nursing facility, extended care/assisted living facility and patient’s home. Nursing facilities will bill for invasive ventilation management on a per day basis with CPT 94004 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; nursing facility, per day).
If providing home ventilation management services, CPT code 94005 can be billed once per month. This code represents physician oversight and revision of the patient’s plan of care based on clinical status, laboratory values or results of other studies. The code description reads as follows: home ventilator management care plan oversight of a patient (patient not present) in home, domiciliary or rest home (e.g., assisted living) requiring review of status, review of laboratories and other studies and revision of orders and respiratory care plan (as appropriate), within a calendar month, 30 minutes or more
Both of the above codes may be billed with revenue code 0410.
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July 26, 2010
Question:
Can code 94662 be assigned for a hospital inpatient, and, if so, how can we bill it?
Answer:
Continuous negative pressure ventilation (CNP), initiation and management is usually not employed in the acute situation, but rather is used as a means of intermittent support for chronic lung failure. Services are billed per day, not per hour, for CNP. Use revenue code 0410.
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July 19, 2010
Question:
What code should be used to report the measuring of peak flow rate?
Answer:
Medicare pays for CPT code 94150 (vital capacity, total [separate procedure]) as an ancillary service under the hospital outpatient prospective payment system (OPPS). Many facilities have this code assigned to line items described as “peak flow.”
In the 2001 CPT Companion, the American Medical Association (AMA) 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.
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July 12, 2010
Question:
Can code 94200 be billed on the same date as 94010?
Answer:
Because maximal voluntary ventilation (MVV) or maximal breathing capacity (MBC) is considered a component of the following codes, billing 94200 on the same date of service as 94010, 94060 or 94070 is double billing and will result in a denial.
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July 5, 2010
Question:
My question relates to code 94010 (spirometry). Which components of this procedure must be performed to use this code?
Answer:
All components of the description must be ordered and performed and medically necessary for appropriate payment by the federally funded programs. As listed in the CPT code description, this includes the following: graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation.
If you do not perform the spirometry as described, you cannot use this code. If you do everything described plus additional parameters, then you can bill 94010 plus the extra tests.
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June 28, 2010
Question:
Can you provide information on Medicare’s documentation requirements for pulmonary function testing?
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 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.
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June 21, 2010
Question:
Is there a way to ensure that a respiratory therapy service meeting Medicare's
medical necessity standards before a claim is submitted?
Answer:
Determinations of medical necessity are made based on local contractor determinations (LCDs) on a claim-by-claim basis. Be sure to always check your Medicare payer's LCDs before submitting your claim.
There appears to be at least one general rule about when respiratory therapy services are not medically necessary, according to the Centers for Medicare & Medicaid Services. Specifically, they are not necessary when a service performed is part of a standard protocol without regard to the individual patient's actual condition, capacity for improving, and the need for such services as established.
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June 14, 2010
Question:
What is the coverage for respiratory therapists in skilled nursing facilities?
Answer:
Medicare covers the full range of services that skilled nursing facilities (SNFs) generally provide, either directly or under arrangements with any qualified outside source. As a result, the services of respiratory therapists are now covered when provided under arrangements made directly between the SNF and any qualified respiratory therapist, regardless of whether the therapist is employed by the SNF's transfer agreement hospital. (This information can be found in Chapter 8, §50.8.2 of the Medicare Benefit Policy Manual.)
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June 7, 2010
Question:
Can the evaluation and management services provided by respiratory therapists
and technicians be charged?
Answer:
Evaluation and management (E&M) services are inherent in the administrative operations of the respiratory therapy department. The cost for patient E&M by the therapist is calculated into the charge for therapeutic or diagnostic procedures billed by the department.
With one exception, It is not appropriate to generate a separate charge for patient E&M or assessment and education. The exception is the procedures included in CPT 94664 (demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device). RT departments do not typically have the need for CPT codes 99201-99215 to be included as billable items on the department chargemaster.
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May 31, 2010
Question:
For the new policy on pulmonary rehab programs, are there specific criteria
that must be met?
Answer:
Effective January 1, 2010, Medicare Part B pays for PR programs and related items and services if specific criteria is met by the Medicare beneficiary, the PR program itself, the setting in which it is administered, and the physician administering the program. For the latest information on the PR program, see the Medicare Claims Processing Manual, Chapter 32, sections 140, 140.4 and 140.4.1 at http://www.cms.gov/manuals/downloads/clm104c32.pdf.
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May 24, 2010
Question:
Does Medicare have any rules about the length of pulmonary rehab sessions?
Answer:
As specified at 42 CFR 410.47(f), pulmonary rehabilitation program sessions are limited to a maximum of two one-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions if medically necessary. Medicare payers will accept the KX modifier on the claim lines as an attestation by the provider that documentation is on file verifying that further treatment beyond the 36 sessions is medically necessary up to a total of 72 sessions for that beneficiary.
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May 17, 2010
Question:
I am looking for information about the new pulmonary rehab information
that was included in a recent federal law. Can you assist?
Answer:
Effective January 1, 2010, a physician-supervised, comprehensive pulmonary
rehabilitation program that includes the following mandatory components
took effect:
- Physician-prescribed exercise;
- Education or training;
- Psychosocial assessment;
- Outcomes assessment; and
- An individualized treatment plan.
Detailed policy and claims processing instructions can be found in the
following documents:
- Medicare Benefit Policy Manual, chapter 15, §231 at
http://www.cms.gov/manuals/Downloads/bp102c15.pdf;
- Medicare Claims Processing Manual, chapter 32, §140 at http://www.cms.gov/manuals/downloads/clm104c32.pdf;
- Transmittal 1966 (May 7) at http://www.cms.gov/transmittals/downloads/R1966CP.pdf.
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May 10, 2010
Question:
My question relates to codes 99406 and 99407, which are used to report
visits for smoking and tobacco-use cessation counseling. Is there a billing
rule related to the minutes listed in the code description?
Answer:
As stated in the code description, 99406 should be used to report face-to-face smoking and tobacco-use cessation counseling, intermediate, greater than three minutes and up to 10 minutes. When the visit is more than 10 minutes, code 99407 should be assigned.
The codes do not represent billable increments of time and are not reported as "add-on" codes; report only one CPT per encounter.
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May 3, 2010
Question:
Can CPT code 94002 be reported for ED services?
Answer:
According to CPT coding guidelines, this ventilation assist and management code is not reportable for services provided in the emergency department (ED). Code 94002, which took effect for services reported on or after January 1, 2007, can be assigned for initial ventilator management services in a hospital inpatient setting or observation.
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April 26, 2010
Question:
What codes are appropriate for physician billing of ventilator management?
Answer:
Medicare recognizes the ventilator codes (CPT codes 94002-94004, 94660 and 94662) as physician services payable under the Medicare physician fee schedule (MPFS). Medicare Part B under the MPFS does not pay for ventilator management services in addition to an evaluation and management service (e.g., critical care services, CPT codes 99291-99292) on the same day for the patient even when the evaluation and management service is billed with CPT modifier -25.
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April 19, 2010
Question:
When a patient is on BiPAP or CPAP, we charge a daily charge. When the
patient is to be taken off, RT leaves the equipment in the room for 24 hours
to ensure that the patient will not need it again. Can we charge separately
for the extra time?
Answer:
There is no additional charge for the maintenance of equipment or the set-up and breakdown of equipment that is left with a patient during standby. The billable service begins and ends with the therapeutic delivery of care with either CPAP or BiPap.
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April 12, 2010
Question:
If the pulmonologist diagnoses COPD and asthma together, what diagnosis
codes should be used?
Answer:
First, carefully check the documentation to identify key terms used by
the pulmonologist. Underdocumented details may affect the most specific
ICD-9 code selection.
Here are the possible choices for the asthma:
- 493.20 - Chronic obstructive asthma, unspecified
- 493.21 - Chronic obstructive asthma with status asthmaticus
- 493.22 - Chronic obstructive asthma with acute exacerbation.
Although code 493.20 is an option, it isn't as specific as the other choices.
Before assigning it, ask the physician whether the patient has status asthmaticus
or an acute exacerbation. If the answer is "no," you may use 493.20.
If status asthmaticus is documented along with COPD, list that diagnosis
first. You may assign 493.21, but not 493.22, if this is the case.
Assigning a COPD diagnosis code also requires comprehensive details in the
documentation, including signs, symptoms and conditions. Also review the
history of present illness and the review of systems to ensure they support
COPD diagnosis as well as the tests ordered and associated therapeutic drug
treatment.
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April 5, 2010
Question:
Can we charge separately for oxygen use during pulmonary rehab? We have
some patients on high flow O2 with exercise, and staff indicated that the
patient couldn't supply that from their own O2 for the length of time they
are in rehab doing one or two sessions.
Answer:
O2 is a billable service as a supply as long as it is medically necessary and consumption is documented.
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March 29, 2010
Question:
What CPT code do you use for physician billing of ventilator management
in the ER?
Answer:
Medicare recognizes the ventilator codes (CPT codes 94002-94004, 94660, and 94662) as physician services payable under the Medicare physician fee schedule (MPFS). Medicare Part B under the MPFS does not pay for ventilator management services in addition to an evaluation and management service (e.g., critical care services, CPT codes 99291-99292) on the same day for the patient even when the evaluation and management service is billed with CPT modifier 25.
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March 22, 2010
Question:
Medicare states that oxygen charges should be billed with the revenue
code 0271, designating it as a supply. It must be billed in "measurable"
units, such as per liter, per hour, per quarter hour, per minute along with
a written order for the oxygen. Our question is if we document measurable
units of service by liter per minute but do not specify the exact hours
of use and bill a daily charge is this acceptable?
Answer:
As long as the final charge can be correlated to O2 consumed your should have no problem defending it.
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March 15, 2010
Question:
When fiducial markers are used before a bronchoscopy procedure, what code
is used?
Answer:
According to the American Medical Association in CPT Assistant, February 2010, code 31626 should be used for this procedure. The type of markers used does not alter the use of this code. It says, "Although one or more markers may be used, code 31626 is not reported for each marker placed."
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March 8, 2010
Question:
How many sessions are covered under the new outpatient coverage of pulmonary
rehab?
Answer:
For 2010 (effective January 1), the Centers for Medicare & Medicaid Services (CMS) established reimbursement under the outpatient prospective payment system (OPPS) for coverage of the new, comprehensive pulmonary and intensive cardiac rehabilitation services furnished to beneficiaries with chronic obstructive pulmonary disease (COPD), cardiovascular disease, and related conditions.
In answer to your specific question, pulmonary rehabilitation (PR) is now
covered for up to 36 one-hour sessions, with a maximum of two sessions per
day, and with contractor discretion to approve to up to 72 sessions. PR
settings were not expanded to include comprehensive outpatient rehabilitation
facilities (CORFs); in this setting, the current HCPCS codes are G0237,
G0238, and G0239.
CMS included coverage for patients with "very severe COPD." It
stopped short of covering other conditions beyond COPD, but it will continue
to provide coverage for those diagnoses currently covered under local PR
coverage policies.
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March 1, 2010
Question:
I am looking for information on how to bill for spirometry for an infant
or a child.
Answer:
In the 2010 CPT Manual, the American Medical Association added three new codes for this procedure: 94011, 94012, and 94013. These are an expansion of the base code 94010 describing basic spirometry measurements. The new codes were created specifically to address the clinical need to code for tests and measurements performed on an infant or child through two years of age.
Be sure to check the manual and read the description carefully. Note that all of the codes are preceded by a "bull's-eye" symbol, which means that their definitions include moderate sedation. Therefore, when these procedures are performed, the CPT code for moderate sedation is not separately reportable by any provider, even if the service is initiated.
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February 22, 2010
Question:
How or what can you charge for end tidal CO2 monitoring? We just got a
hand-held end tidal CO2 monitor and want to know if we can get any charges
for checking patients with a cannula (sidestream sampling). Do you know
the code?
Answer:
Sidestream end tidal CO2 monitoring does not have a separate CPT code for reporting.
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February 15, 2010
Question:
We are using a simple pulmonary stress test (code 94620) as part of a
diagnostic work-up for heart failure patients, and the code represents a
fair amount of reimbursement for what we do. The code is an active one in
our intermediary's local coverage determination (LCD) for pulmonary rehabilitation
services, and staff sent me a list of diagnosis codes but these are not
why we use the test. Can we get paid for using it for another purpose?
Answer:
As far as coverage indications for a particular code go, providers are really at the mercy of the LCDs.
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February 8, 2010
Question:
I receive many emails from our billing staff about medical necessity for
a simple stress test 94620. They say that the code is an active one in our
intermediary's local coverage determination (LCD) for pulmonary rehabilitation
services, and they sent me a list of diagnosis codes. But we are not using
94620 in relation to pulmonary rehab, and we do not encounter the diagnoses
listed in the LCD. We use the test as part of a diagnostic work-up for heart
failure patients, and the the code represents a fair amount of reimbursement
for what we do.
Answer:
You don't have a medical necessity issue, you have a coding and semantics
issue.
The procedure that you are actually performing, as evidenced by the records
you provided to us, is CPT 94761--pulse oximetry for oxygen saturation,
multiple determinations (e.g., during exercise). In order to report CPT
94620, pre and post spirometry as well as oximetry must be performed. In
the records provided, I see no evidence of spirometry testing. Heart rate,
blood pressure and pulse oximetry are the only parameters measured.
The CHFPA 6 Minute Walk Test, as defined on the form used to report the
study, is a cardiopulmonary exercise test, not the walk test defined by
CPT 94620.
Implement reporting of CPT 94761, and medical necessity shouldn't be an
issue.
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February 1, 2010
Question:
Could you please review appropriate performance and reporting of the six-minute
walk test that is reported with 94620?
Answer:
The descriptor for CPT 94620 was revised in 2007 to include a six-minute walk test and oximetry in the example in the descriptor. A six-minute walk test that evaluates distance, dyspnea, oxyhemoglobin desaturation and heart rate can be reported with CPT 94620 according to the AMA July 2005 CPT Assistant. Spirometry is not required but the heart rate, blood pressure, oxygen saturation are to be be reported at rest, during exercise, and during recovery.
The CPT Assistant points out that a six minute walk test with no objective
ventilatory assessments should should be reported with CPT 94761, noninvasive
ear or poulse oximetry for oxygen saturation; multiple determinatios (eg,
durging exercise).
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January 25, 2010
Question:
How is code 94762-pulse oximetry; continuous overnight determination-for
hospital outpatients paid?
Answer:
Under the hospital outpatient prospective payment system (OPPS) guidelines, some services are designated as "special packaged" procedures. C codes categorized as Q1 are reimbursed according to APC assignment when they appear on a claim with no other separately payable OPPS procedure carrying an S, T, V, or X status indicator (SI). This category applies to code 94762.
When medical necessity has been met for performance of overnight continuous pulse oximetry as an outpatient procedure and when no other OPPS procedure carrying any of the above SIs is performed on the same date of service (DOS), the procedure will be paid according to APC 0097. If any other qualifying OPPS service is billed on the same DOS, 94762 will be packaged and not separately paid.
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January 18, 2010
Question:
Is there any CPT code we can charge for flutter valve and vest? The flutter
valve is being used on a hospital inpatient. The vests are disposable and
are only used on one patient.
Answer:
Whether you can charge for the flutter valve depends upon when and where this device is being issued and what service is being provided. To provide a code, we would need additional information.
Because the chest vest is a piece of re-usable equipment, it cannot be billed. Nonetheless, some of our clients have chosen to bill for these devices because they are patient-specific and represent a significant non-routine cost to the facility that is difficult to account for as a routine "floor stock" item with a cost factored into the daily room rate. The other factor to consider is the effectiveness of the charge-capture process. In many cases, providers conclude that the current process to capture the charge for the item is too unreliable. so the item's cost is captured by bundling it into the daily room rate or including it into a diagnostic or therapeutic procedure charge.
For additional information, see the respiratory compliance question and answer from October 19, 2009 by clicking here.
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January 11, 2010
Question:
A pulmonologist performs bronchoscopies in our hospital fluoro rooms without
a radiologist. (We do store images.) Is there anything else we can code
along with 76000?
Answer:
According to CPT instructions and guidelines, fluoroscopy is included within the bronchoscopy codes 31622-31646 and would not be billed separately. Be sure to read the guideline in the CPT manual directly under Endoscopy on page 152 of the 2010 professional edition for other specifics.
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January 4, 2010
Question:
Is there any CPT code we can charge for flutter valve and vest? The flutter
valve is being used on a hospital inpatient. The vests are disposable and
are only used on one patient.
Answer:
Whether you can charge for the flutter valve depends upon when and where this device is being issued and what service is being provided. To provide a code, we would need additional information. Because the chest vest is a piece of re-usable equipment, it cannot be billed.
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December 28, 2009
Question:
Is moderate sedation included in the new spirometry codes 94011, 94012,
and 94013?
Answer:
The new codes were created specifically to address the clinical need to code for spirometry tests and measurements performed on an infant or child through two years of age. All three codes are preceded by a "bull's-eye" symbol, which means that their definitions include moderate sedation. Therefore, when this procedure is performed, the CPT code for moderate sedation is not separately reportable by any provider, even if the service is initiated.
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December 21, 2009
Question:
Where would I find out about the new pulmonary rehab coverage for the
Medicare program?
Answer:
On December 11, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 1871, which includes information about the new coverage. Specifically, CMS added Section 140.4 to Chapter 32 (Billing Requirements for Special Services). It includes coverage and coding requirements for pulmonary rehabilitation services beginning January 1, 2010. For this transmittal, go to http://www.cms.hhs.gov/transmittals/downloads/R1871CP.pdf.
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December 14, 2009
Question:
How is code 94762 paid under the outpatient system?
Answer:
Under the OPPS reimbursement guidelines, some services are designated as "special packaged" procedures. C codes categorized as "Q1" will be reimbursed according to APC assignment when they appear on a claim with no other separately payable OPPS procedure carrying an S, T, V, or X status indicator (SI). This category applies to 94762 (pulse oximetry; continuous overnight determination).
When medical necessity has been met for performance of overnight continuous pulse oximetry as an outpatient procedure and when no other OPPS procedure carrying an S, T, V, or X SI is performed on the same date of service, the procedure will be paid according to APC 0097. If any other qualifying OPPS service is billed on the same date of service, 94762 will be packaged and not separately paid.
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December 7, 2009
Question:
Where can I find Medicare's national coverage information for CPAP therapy
for OSA?
Answer:
That information can be found in section 240.4 of the Medicare National Coverage Determinations Manual, Chapter 1 at http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf
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November 30, 2009
Question:
Did CMS finalize its plan to cover pulmonary rehabilitation?
Answer:
Yes, in the 2010 hospital outpatient prospective payment system (OPPS) final rule, the Centers for Medicare & Medicaid Services did establish payment for new, comprehensive pulmonary rehab services for beneficiaries with chronic obstructive pulmonary disease and related conditions. For that final rule, go to http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage, and click on CMS-1414-FC in the first column. Details about the coverage can be found in Section XII.B (pages 890-911).
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November 16, 2009
Question:
When a respiratory therapist performs a venipuncture on patients, how
should this be coded?
Answer:
Report 36415 to all payers including Medicare, which will reimburse once per encounter. Be sure to differentiate between venipuncture, capillary collection, and draws from a line or access device. When collecting capillary specimens (36416), the related cost is considered by Medicare to be insignificant and should be bundled to the test procedure. Blood-specimen collection performed during an IV start is not separately billable.
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November 9, 2009
Question:
Does new code 31627, which you mentioned last week, include 3D reconstruction?
Answer:
Yes, according to the parenthetical note under code 31627 in the 2010 CPT manual, it does include 3D reconstruction.
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November 2, 2009
Question:
I have heard that there are new bronchoscopy codes in the 2010 CPT system.
Can you provide these?
Answer:
The following codes were added to the respiratory system subsection of
the surgery section:
31626 Bronchoscopy, rigid or flexible, including fluoroscopic guidance,
when performed; with placement of fiducial markers, single or multiple
31627 Bronchoscopy, rigid or flexible, including fluoroscopic guidance,
when performed; with computer-assisted, image-guided navigation
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October 26, 2009
Question:
My question relates to apnea monitoring for pediatric patients at home.
What code would be assigned?
Answer:
In addition to monitoring of infants or children in the inpatient or outpatient setting of a hospital, pediatric patients with repeated episodes of apnea or apnea-related disorders may be monitored at home. Code selection (94774, 94775, 94776 or 94777) depends on whether you are billing globally for the complete procedure or for only one component (professional or technical).
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October 19, 2009
Question:
Can codes 94667 and 94668 be used for high frequency chest wall oscillation
devices (i.e..vest), intermittent percussive ventilation (IPV), acapella/flutter
device or continuous high frequency oscillation devices (i.e., MetaNeb)?
Each of these devices provides percussion to the chest.
Answer:
The vest is a piece of re-usable equipment and is not billable using the codes 94667 / 94668. Typically, the IPV devices are used for patient managed bronchial hygiene therapy and do not require the expertise of the therapist for delivery of therapy. Note that the introduction and demonstration of the IPV devices are not included in CPT 94664, so this would also not be a billable service.
The CPT codes 94667 / 94668 should be reserved for billing of therapy that
requires the expertise of the therapist to provide hands-on therapy. Refer
to the AARC Clinical Practice Guideline for Postural Drainage Therapy,
which provides definition for turning procedures, postural drainage procedures
and external manipulation procedures (percussion and vibration).
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October 12, 2009
Question:
A pulmonologist performs bronchoscopies in our fluoro rooms at the hospital
without the radiologists (we do store images). Is there anything else we
can code along with 76000?
Answer:
The bronchoscopy codes (31622-31646) include fluoro guidance when provided, so I don't see any code that could be coded (not even 76000). o 76xxx or fluoro codes should be assigned in addition to the surgical code.
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October 5, 2009
Question:
Does Medicare reimburse for pulse oximetry code 94762?
Answer:
CPT code 94762 (noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring [separate procedure]) is reimbursed only if it is the sole service billed for the encounter. If the procedure is billed with any other OPPS service on a single date of service, the CPT code 94762 is packaged to the significant procedure.
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September 28, 2009
Question:
Does Medicare allow billing for pulse oximetry on inpatient claims? Please
advise if there are different guidelines for ICU versus med/surg and telemetry
patients.
Answer:
When used as a monitor of vital signs, such as typically seen in the nursing
units of ICU and telemetry, this is considered to be a routine service and
is not billable.
Pulse oximetry is billable when utilized as a diagnostic procedure for determination
of oxygen saturation for diagnosis and treatment of the patient. This service
is based on a patient-specific order with saturation levels reported to
the physician for medical decision making such as addition of O2 and/or
titration of oxygen.
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September 21, 2009
Question:
What code should be assigned for coughing exercises?
Answer:
Deep-breathing and coughing exercises are examples of services that do
not generally require the skill of a respiratory therapist. When performed
by the nursing staff they are considered routine services for the purpose
of Medicare coverage. Other services considered as routine include the following:
- Checking to make sure oxygen is on
- Routine nebulizer treatments
- Pulse oximetry readings
- Incentive spirometer treatments
- Oral "puffer" inhalants administration
- Oxygen saturation and titration done on stable chronic COPD patients
- Repetitive patient training in the use of simple respiratory modalities,
breathing techniques and energy conservation.
- Setting up of O2 equipment such as flow meters, tubing, humidifiers, and
nasal canula/simple face masks
- Frequent repositioning and early ambulation
- Bronchial hygiene therapy furnished on a routine basis to preoperative
patients.
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September 14, 2009
Question:
It is my understanding that the three home sleep testing HCPCS G-codes-
G0398, G0399, and G0400-should be used only for physician billing. Is this
correct?
Answer:
HCPCS G-codes are not limited to physician reporting. Since implementation of the OPPS in August 2000, Medicare has recognized HCPCS G-codes for reporting under the OPPS for hospital outpatient services. HCPCS G-codes are a subset of the Level II HCPCS codes and describe temporary procedures and services that are not described by any CPT codes. Created by CMS, this subset of codes is updated on a quarterly basis and may be reported by providers for any health insurers for various sites of services. While the codes may be used by any health insurers, it is up to the individual insurers to provide guidance on the reporting of these codes.
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September 7, 2009
Question:
Can 94010 be billed if only certain elements of the description are performed?
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.
94010 - Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurements(s), with or without maximal voluntary ventilation.
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August 31, 2009
Question:
Do you know whether CMS has released the billing guidelines for the new
coverage of sleep tests?
Answer:
On July 10, the Centers for Medicare & Medicaid Services (CMS) issued
Transmittal 103. That memo includes a new section that will go into the
National Coverage Determinations Manual on the guidelines related
to the following nationally covered tests:
- Type 1 PSG when the test is attended in a sleep lab facility;
- Type II or Type III if performed unattended in or out of a sleep lab facility
or attended in a sleep lab facility; or
- Type IV measuring three or more channels, one of which is airflow, if
performed unattended in or out of a sleep lab facility or attended in a
sleep lab facility.
Implementation of the NCD is now set for August 10, with the new coverage going back to services provided on and after March 3, 2009. For the transmittal, go to http://www.cms.hhs.gov/transmittals/downloads/R103NCD.pdf. For provider information memo MM6534, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6534.pdf.
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August 24, 2009
Question:
My question relates to oxygen uptake codes 94680, 94681 and 94690. Can
calculated test results be separately reported?
Answer:
Based on the methodology used, the result (VO2) may be obtained by direct measure or calculation. Calculated test results are not to be separately reported to Medicare for reimbursement in addition to the tests that are performed to derive such calculations. When performed with either the simple or complex pulmonary stress test, the oxygen uptake procedures are considered a component and should not be separately billed. When documentation supports the billing of the oxygen uptake in addition to the simple stress test, a modifier may be appended.
When performing a complex stress test, the CCI indicates that the oxygen uptake is never separately billable by associating a modifier indicator of "0" with the code pair.
Check with your Medicare payers to determine coverage for your facility.
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August 17, 2009
Question:
Even though the pulse oximetry codes are packaged codes, should we continue
to bill them?
Answer:
You are correct that, under the hospital outpatient prospective payment system (OPPS), the codes for pulse oximetry (94760 and 94761) are assigned to the status indicator "N," meaning that they are incidental services and not separately reimbursed. This by no means indicates that the procedure should not be billed.
Since the implementation of the OPPS in 2000, 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/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). Note, however,
that 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.
Under the previous 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 could not be billed. As a
result of public requests, a special APC subcommittee was formed to consider
payment options for packaged services that are commonly provided alone.
In 2007, CMS introduced a new category for incidental procedures-special
packaged service-and assigned them to a new status indicator of "Q."
There are now six CPT codes listed in this category including 94762. Beginning
January 1, 2007, if the continuous overnight pulse oximetry (94762) is the
only OPPS procedure provided on a given date of service the hospital may
bill and be reimbursed for this service.
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August 10, 2009
Question:
My question relates to code 94240--functional residual capacity or residual
volume helium method, nitrogen open circuit method, or other method. I believe
we have been assigning the right code for the procedure we are performing,
but but our claims are being denied. Do you have any tips on why this may
be occurring?
Answer:
Functional residual capacity (FRC) can be measured with any of several methods (as specified in the descriptor), which must be specified. Also, investigate coverage criteria applicable to your state. Medicare is very restrictive in paying for "screening" tests, and pre-op workups can often carry a "V" code for the ICD-9-CM code, one which will result in a denial of all pre-op services. Ensure proper medical necessity documentation is submitted by the physician and then on the claim form.
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August 3, 2009
Question:
Has CMS proposed any 2010 changes for the hospital OPPS related to respiratory
services?
Answer:
One major change relates to the proposed payments for services furnished
to hospital outpatients in a pulmonary rehabilitation program. For 2010,
the Centers for Medicare & Medicaid Services (CMS) have proposed the
following new Level II HCPCS code for hospitals to report and bill for the
services furnished: GXX30 (pulmonary rehabilitation,
including aerobic exercise [includes monitoring], per session, per day).
You can read all of the details beginning on page 35360 of the PDF version of the proposed rule. Go to http://www.access.gpo.gov/su_docs/fedreg/a090720c.html and scroll down to Centers for Medicare & Medicaid Services, Proposed Rules, Medicare Program.
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July 27, 2009
Question:
Are the specific sleep tests for obstructive sleep apnea covered by national
or local determinations?
Answer:
Previously, although CPAP was nationally covered for beneficiaries with
obstructive sleep apnea (OSA) if diagnosed with specific tests, coverage
of the tests themselves was left to local contractor discretion. However,
a new national coverage determination (NCD) takes effect on Augusts 10,
2009, and Medicare will allow for coverage of the sleep testing devices,
specifically:
- Type 1 PSG when the test is attended in a sleep lab facility;
- Type II or Type III if performed unattended in or out of a sleep lab facility
or attended in a sleep lab facility, or;
- Type IV measuring 3 or more channels, one of which is airflow, if performed
unattended in or out of a sleep lab facility or attended in a sleep lab
facility.
For more on this, go to https://www.cms.hhs.gov/transmittals/downloads/R103NCD.pdf.
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July 20, 2009
Question:
Our hospital has trouble getting paid for code 94762. Can we provide any
guidelines on why this may be occurring since we have met the medical necessity
requirements?
Answer:
In the 2007 hospital outpatient prospective payment system (OPPS) final rule, the Centers for Medicare & Medicaid Services (CMS) introduced the new status indicator of Q, which categorizes a select group of CPT codes as "special packaged items," and code 94762 (pulse oximetry; continuous overnight determination) is one of those codes.
Procedure codes categorized as Q will be reimbursed according to APC assignment when they appear on a claim with no other separately payable OPPS procedure. When medical necessity has been met for performance of overnight continuous pulse oximetry as an outpatient procedure and when no other OPPS service is performed on the same date of service, the procedure will be paid according to APC 0443. If any other OPPS service is billed on the same date of service, 94762 will be packaged and not separately paid.
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July 13, 2009
Question:
Does the hospital outpatient proposed rule for 2010 include anything of
interest to respiratory specialists?
Answer:
To implement additional benefits authorized by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), the Centers for Medicare & Medicaid Services (CMS) proposes to establish outpatient prospective payment system (OPPS) payment for pulmonary and intensive cardiac rehabilitation services furnished to beneficiaries with chronic obstructive pulmonary disease, cardiovascular disease, and related conditions, effective January 1, 2010. The new benefits would apply to services provided in a physician's office, in a hospital on an outpatient basis, or in other settings as the Secretary of the Department of Health & Human Services determines to be appropriate.
For the 2010 proposed rule for the hospital OPPS and ASCs, go to http://www.federalregister.gov/OFRUpload/OFRData/2009-15882_PI.pdf. Information about the above begins on page 434.
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July 6, 2009
Question:
Does Medicare have QA guidelines for respirators?
Answer:
The Department of Health and Human Services (HHS) published a proposed rule on the quality assurance requirements for respirators on December 10, 2008. (For this proposed rule, go to http://www.access.gpo.gov/su_docs/fedreg/a081210c.html, and scroll down to Health and Human Services Department.)
Since then, HHS has held two public meetings to gain comments from the industry. In response to one commenter, HHS recently extended the public comment period, noting that the costs associated with the proposed QA requirements related to inspections, audits, documentation, complaint management, and document control administration are significant. Therefore, it reopened the comment period for this proposal until October 9, 2009. For the May 21 proposed rule, go to http://www.access.gpo.gov/su_docs/fedreg/a090521c.html, and scroll down to Health and Human Services Department.
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June 29, 2009
Question:
In last week's answer, you provided guidelines for complying with Medicare's
medical necessity requirements. But what can be done when the physician
orders a sleep study but has not performed the required diagnostic tests?
Answer:
According to many reimbursement experts, physicians often order a sleep study without performing the needed diagnostic tests to establish that the study 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. This is a simple evaluation to find out how likely a person is to fall asleep in a variety of situations, using a scale of 0 (no chance of dozing) to 3 (high chance of dozing).
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. These may be listed in a national coverage determination (NCD) or in a local coverage determination (LCD).
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 upfront that Medicare does not consider the procedure to be medically necessary.
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June 22, 2009
Question:
Our hospital has a difficult time being reimbursed for sleep studies by
Medicare. Can you provide some guidelines for changing this occurrence?
Answer:
When Medicare does not reimburse hospitals for sleep studies, the most common reason is the lack of medical necessity. The Social Security Act (the federal law governing the Medicare program) specifically excludes from coverage "items and services not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member."
To comply with Medicare's medical necessity requirements, be sure to do
the following:
- 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.
- The facility should require a recent (within the last two to three months)
history and physical detailing the signs and symptoms related to the sleep
testing prior to the patient's study.
- Pay close attention to a procedure's frequency limitations for coverage,
which may be available from your FI/Part A MAC 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.
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June 15, 2009
Question:
Are there guidelines as to when Medicare views pulmonary stress testing
(94620-94621) as medically necessary?
Answer:
Generally, the pulmonary stress test will be considered medically necessary
for the following:
- To determine whether the patient's exercise intolerance is related to
pulmonary disease, cardiac disease, or due to lack of conditioning or poor
effort;
- For an initial diagnostic workup when symptoms (generally dyspnea) are
out of proportion to findings on static function (spirometry, lung volume,
diffusion capacity);
- For the detection of interstitial lung disease (fibrosis) or exercise-induced
bronchospasm that are only manifested by exercise; and/or
- To evaluate patient's response to a newly established pulmonary treatment
regimen.
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June 8, 2009
Question:
Are there any frequency limits for a pulmonary compliance study?
Answer:
For CPT code 94750 (pulmonary compliance study, any method), you should check with your fiscal intermediary (FI) or Medicare administrative contractor (MAC) for frequency limits with which the procedure will be reimbursed. Frequency limits vary based on the clinical diagnosis provided.
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June 1, 2009
Question:
As an answer to a question posted for March 2, you stated the following: "Providers should classify oxygen as a supply and bill under UB-04 revenue code 271. No HCPCS codes are required, and none should be reported. Oxygen is billable when a valid order is present and measurable units of service are documented."
How does this relate to the information in Chapter 20 of the Medicare
Claims Processing Manual?
Answer:
The instructions in Chapter 20 apply only to the DMEPOS benefit and the
statement above is intended to explain to providers that Medicare will not
pay for the DMEPOS benefit while the patient is in a covered Part A stay.
In general, the DMEPOS benefit is meant only for items a beneficiary is
using in his or her home. For a beneficiary in a Part A inpatient stay,
an institutional provider (e.g.,hospital) is not defined as a beneficiary's
home for DMEPOS, and so Medicare does not make separate payment for DMEPOS
when a beneficiary is in the institution. The institution is expected to
provide all medically necessary DMEPOS during a beneficiary's covered Part
A stay.
See Medicare Claims Processing Manual, Chapter 20, Section 210, CWF
Crossover Editing for DMEPOS Claims During an Inpatient at http://www.cms.hhs.gov/manuals/downloads/clm104c20.pdf.
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May 25, 2009
Question:
For hospital inpatient accounts, is the supply of oxygen a separately
billable charge when ventilator management services are provided and billed
at the same time?
Answer:
Some providers calculate the average cost of oxygen and bundle that cost into the ventilator charge. However, because usage varies by patient, providers should classify oxygen as a supply and bill under UB-04 revenue code 271. No HCPCS codes are required, and none should be reported. Oxygen is billable when a valid order is present and measurable units of service are documented.
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May 18, 2009
Question:
Could you please tell me when it is appropriate to bill codes 94010 vs
94060, and how and when they should be used?
Answer:
CPT 94010 is typically the initial procedure--spirogram--in determining
the underlying cause of a respiratory condition or disease. The procedure
is used in the initial stages of the diagnosis process to differentiate
between obstructive and restrictive disorders. Based on the preliminary
results of the spirogram, additional procedures may be indicated to provide
the physician with a definitive diagnosis. Depending on the results, generated
either a bronchodilation responsiveness evaluation (94060) or bronchospasm
provocation evaluation (94070) may be indicated.
Bronchodilation responsiveness evaluation consists of the study of bronchospasms
by performing spirometry before and after delivery of a bronchodilator treatment.
This procedure is commonly referred to as a before-and-after PFT or a complete
PFT, which may also include the performance of TGV, FRC and DLCO. When billing
for the bronchodilation responsiveness evaluation, the spirometry as described
by 94010 will have been performed twice.
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May 11, 2009
Question:
For thoracic gas volume, should code 93720 or 94260 be assigned?
Answer:
When determining which code-93720 or 94260-most accurately represents the procedure to be billed, consider the documentation, billing requirements and coverage of all payers including Medicare.
According to the national correct coding initiative (CCI) edits, 94260 is a component of 93720 (total body plethysmography), which represents the global fee for a diagnostic pulmonary evaluation that measures thoracic gas volume, compliance of the lung, airway resistance and airway conductance. You cannot bill both codes on the same date of service. In fact, if you report the CPT code 93720, you cannot bill for CPT code 94360 (airway flow resistance) or CPT code 94750 (pulmonary compliance study) for the same encounter. Unless clinical circumstance justifies appending a modifier, this code may be denied when used on the same date of service with 94240 for certain diseases.
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May 4, 2009
Question:
If a therapist responds to and provides intervention such as intubation,
CPR, and ventilation management during a hospital emergency situation, can
this be billed separately as an evaluation and management (E&M) service?
Answer:
This service is inherent in the administrative operations of the hospital's
respiratory therapy department. The cost for patient E&M by the therapist
is calculated into the charge for therapeutic or diagnostic procedures billed
by the department. Generally, it is not appropriate to generate a separate
charge for E&M of the patient or for patient assessment and education.
The only exception would be procedures included in the following CPT code:
- 94664 Demonstration and/or evaluation of patient utilization of an aerosol
generator, nebulizer, metered dose inhaler or IPPB device
Respiratory therapy departments do not typically have the need to include E&M CPT codes 99201-99215 as billable items on the department chargemaster.
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April 27, 2009
Question:
Will Medicare pay for incentive spirometry for outpatients?
Answer:
No separate outpatient reimbursement will be made by Medicare for the measurement (and result recording) of the forced expiration (peak flow) or the maximal inspiration (incentive spirometry). Both services fail to meet the definition of spirometry as defined by CPT code 94010.
It is possible that some payers, other than Medicare and Medicaid, MAY reimburse for these services, however, most third-party payers generally follow the guidelines of the federally funded programs. Medicare payments for outpatients are based on the CPT code; therefore, care must be taken to avoid misrepresenting services to Medicare with CPT codes that inaccurately describe the service provided.
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April 20, 2009
Question:
Can you provide any resources for documentation requirements related to
asthma?
Answer:
On August 28, 2007, the National Heart, Lung and Blood Institute (NHLBI) issued Guidelines for the Diagnosis and Management of Asthma (Expert Panel Report 3 [EPR3]). Section 5 of that document includes guidelines that address managing exacerbations of asthma. These guidelines can be downloaded at http://www.nhlbi.nih.gov/guidelines/asthma/11_sec5_exacerb.pdf.
In a nutshell, the report is organized around four essential components
of asthma care: assessment and monitoring, patient education, control of
factors contributing to asthma severity, and pharmacologic treatment. It
then developed the following subtopics are these components:
- 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.
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April 13, 2009
Question:
Can you provide the key billing guidelines related to code 94610 (intrapulmonary
surfactant administration by a physician through endotracheal tube)?
Answer:
Routine monitoring includes heart rate, respirations, chest expansion, breath sounds, blood pressure and oxygen saturation by pulse oximetry. As a routine monitor, the use of pulse oximetry is not separately billable.
The administration of surfactant rarely, if ever, occurs in the outpatient setting of the hospital. However, CMS recognizes the code for separate OPPS payment.
In the hospital inpatient setting, this procedure is performed by respiratory therapists under the "incident to" guidelines, meaning that the physician does not have to be present but that the service is performed under the direction of the physician's order.
Report code 94610 only one time per dosing episode regardless of the number of administrations of the surfactant per episode.
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April 6, 2009
Question:
What is the correct way to bill for the repair of beneficiary-owned DME
and oxygen equipment?
Answer:
On February 13, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 443, which lists new HCPCS Codes for the repair or nonroutine service of durable medical equipment (DME). CMS states that the two new K codes below are effective for claims with dates of service on or after April 1, 2009.
K0739 - Repair or nonroutine service for DME other than oxygen equipment
requiring the skill of a technician, labor component, per 15 minutes
K0740 - Repair or nonroutine service for oxygen equipment requiring the
skill of a technician, labor component, per 15 minutes
These should be used to distinguish between the repair or nonroutine service of beneficiary-owned DME and oxygen equipment. For more information on this topic, go to http://www.cms.hhs.gov/transmittals/downloads/R443OTN.pdf.