How to code for home sleep studies, pulmonary rehabilitation services

August 6, 2010

Understand how to bill with the 94660 code to get reimbursed properly.

Key Points

Q: Our sleep lab in California has been open for 12 years, but with the new codes for home sleep studies (G0399, 95806), we are trying to get a grasp on the changing environment. My questions is regarding the 94660 code (CPAP initiation and management). As doctors are billing their recurring office visit (99211–99215), they are getting denied billing the 94660. When they bill this code separately from an office visit, however, they are getting reimbursed. Is 94660 an appropriate non-face-to-face code? Also, is it appropriate to bill this code quarterly-or even monthly?

Second, the 94660 code is to be used for the initiation and management of CPAP therapy. When the treatment is initiated with the patient, it is appropriate to bill 94660 for the initiation and instruction of the patient. If the patient returns and requires additional instruction on use or other issues related to the use of the CPAP device, it would be appropriate to bill that service again. If, on those occasions, a separately identifiable service occurs (the visit is not solely for management of the patient's use of the CPAP machine), it would be appropriate to bill a level of office visit in addition to the 94660, adding the modifier 25 to the evaluation and management service showing that it is a separate service from the CPAP management.

Insurer requirements to bill this service may vary. Make sure you know the criteria for your major insurers.

Q: We recently discovered that pulmonary rehabilitation is a Medicare-reimbursable service in an office setting and that this change was effective January 1. Historically, we have performed pulmonary rehabilitation services only in an outpatient facility because we were unaware that the services were reimbursable in our office.

The notice we received was issued May 7, was effective January 1, and has an implementation date of this coming October 4. We are confused. Can we perform those services in our office now? How should those services be reported? If the implementation date is October 4, will we be paid for services reported now?

A: Although the Medicare Improvements for Patients and Providers Act of 2008
added payment and coverage for rehabilitation of chronic obstructive pulmonary disease and other pulmonary conditions under Part B, numerous mandatory requirements exist. The Medicare Benefit Policy Manual, Pub. 100–02, chapter 15, section 231 (see transmittal R124BP, issued May 7, at http://www.cms.gov/Transmittals/2010Trans/list.asp and the Medicare Claims Processing Manual, Pub. 100–04, chapter 32, section 140 (at https://www.cms.gov/Manuals/IOM/list.asp) detail the requirements and claims filing instructions.

Service is reported with code G0424. Claims for pulmonary rehabilitation with a place of service 11 (office) will not be recognized for payment until October 4.

The author is president of Healthcare Consulting Associates of NW Ohio Inc. and is a Medical Economics consultant. She has more than 30 years of experience as a practice management consultant and also is a certified coding specialist, certified compliance officer, and certified medical assistant. Do you have a primary care-related coding question for our experts? Send it to medec@advanstar.com
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