Pulmonology Coding Alert

Thanks to two Medicare policy changes, you'll now be able to use home sleep test confirmed OSA as a carrier covered CPAP reason and an EMR-generated, unsigned x-ray order as an acceptable diagnostic test.

CMS revised Change Request (CR) 6048, "Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA)," to expand acceptable tests for coverage. Medicare will now allow coverage of CPAP therapy based on a positive diagnosis of OSA by unattended home sleep testing, subject to the policy's requirements. This is a change from CMS's National Coverage Determination (NCD) of 2005.

Old version: Previously, Medicare covered the use of CPAP only in beneficiaries who had been diagnosed with moderate to severe OSA (327.23, Obstructive sleep apnea [adult] [pediatric]). A physician had to order the test and confirm the patient's diagnosis by polysomnography performed in a sleep lab (95808-95811) in accordance with other CMS guidelines.

The change: The revised policy allows CPAP coverage based on a positive OSA diagnosis via home sleep test (HST). CMS deleted the requirements that the patient have moderate to severe OSA and that surgery be a likely alternative. The case must comply with other requirements outlined in CR6048 and described in the sidebar "Watch for These 3 Additional CPAP Criteria" on page 74.

Pulmonologists will have to be diligent in indicating HST because charge tickets won't offer a coordinating ICD-9 code to circle.

"There currently is no code for HST," says Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy, and critical care at Emory University School of Medicine in Atlanta.

Instead: "The physician should document that he feels the Medicare patient clinically has a high likelihood of having OSA and describe the HST the patient had," Plummer stresses. HST documentation should describe two details:

• Include the sleep parameters monitored, such as oxygen saturation, airflow or ventilation, ECG or heart rate, EEG, or other measures, Plummer says.

• Indicate the type of device used for the home sleep test (Type II-IV).

Important: Revised policy CR 6048 is retroactive for claims with dates of service on and after March 13, 2008. If you processed claims eligible for CPAP coverage under the new policy, be sure to resumbit for reprocessing -- and payment.

Want more? To see the official instruction, visit the CMS Web site (http://www.cms.hhs.gov) and search for Transmittal R94NCD.

CR 6100 updates information in the Medicare Benefit Policy Manual about physician signature requirements for diagnostic tests (Chapter 15, Section 80.6.1). The manual inadvertently omitted information from Section 15021 of the Medicare Carriers Manual, so the new policy corrects that.

The change: A physician's signature is not required on orders for clinical diagnostic tests paid based on the clinical laboratory fee schedule, Medicare physician fee schedule, or physician pathology services. Procedures affected by the change include x-ray, laboratory, and other diagnostic tests.

The new policy states that your physician is not required to sign the order, but other documentation must be in place. Ensure that your physician clearly documents in the patient's medical record his intent that the test be performed.

Example: If the patient needs a chest x-ray, the pulmonologist should write in the record that the patient requires a chest X-ray for a specific reason (such as a follow-up after pneumonia).

Log on to the CMS Web site and search for R94BP for more information about physician signature requirements for diagnostic tests.

"This policy change is an attempt by CMS to reflect current practice," says Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "In light of the electronic medical record, orders can be generated and authorized by the physician but may not have a signature (electronic or otherwise)."

Caution: Facility-based practices may have facility-imposed guidelines requiring a signature on orders despite the fact that federal guidelines do not require it, Pohlig stresses. Always check the guidelines for a particular case or payer to ensure correct reporting.