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Pulmonology Coding Alert

CMS Approves National Coverage Policy for Mild OSA

Published on Tue Jan 01, 2002

CMS recently said it intends to expand Medicare coverage of continuous positive airway pressure (CPAP) to include beneficiaries who have mild, symptomatic obstructive sleep apnea (OSA). Medicare now covers CPAP only in beneficiaries with moderate to severe OSA. Teresa Thompson, a coding specialist in Sequim, Wash., says Medicare carriers now define the severity of OSA by the number of apneic events during a sleep study, and every carrier has a different local medical review policy, which can get confusing. "Therefore, the national coverage policy should help in that regard," she says.
 
Note: To view the full coverage decision, go to www.hcfa.gov/coverage/8b3-bbb.htm.
 
CMS reconsidered its coverage policy after hearing concerns from manufacturers, clinicians and professional associations that the current national coverage policy was outdated and inconsistent with today's standards of practice. "CMS is working on the instructions to implement the national coverage decision for CPAP, and doesn't yet know the implementation date," says Francina Spencer, CMS health insurance specialist, Division of Items and Services.

Billing Tips for OSA

Pulmonologists should follow these guidelines:
 
Office visits. For a new patient with symptoms of OSA, use E/M codes 99201-99205 (new patient, office or other outpatient visit). For a follow-up or evaluation of an established patient with OSA, use 99211-99215 (established patient, office or other outpatient visit). A consult would be billed 99241-99245 (office or other outpatient consultations).
 
CPAP. "The physician can only bill CPAP (94660) if it is initiated by the physician in the office," says Carol Pohlig, BSN, RN, CPC, a reimbursement analyst for the University of Pennsylvania department of medicine in Philadelphia. "This code is listed in the Correct Coding Initiative (CCI), which is available from the National Technical Information Service: (800) 363-2068. Code 94660 should not be reported with an office visit. If the CPAP was initiated at home, it cannot be reported as part of the office services. Only the office visit is reported (99211-99215 or 99201-99205)."
 
BiPAP is also coded as 94660 even though it uses a slightly different mechanism than CPAP.
 
Sleep studies. Sleep studies have to be more than six hours long to qualify as complete studies, Thompson says. "You should code a complete sleep study with CPAP using 95811 (polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist), and without CPAP use 95810 (... sleep staging with 4 or more additional parameters of sleep, attended by a technologist)," she says.
 
Professional component for interpreting sleep study tests. Most physicians don't have their own sleep lab, and can only bill for the professional component, e.g., inter-preting the test. "In this case, use modifier -26 (professional component) to indicate this," Thompson says. "For the ICD-9 code to show medical necessity, use the definitive diagnosis from the sleep study, which for OSA would most likely be 780.53 (hypersomnia with sleep apnea). If you don't have a definitive finding after the study, use the ICD-9 codes for the signs and symptoms that prompted the study."
 
According to CMS, symptoms of OSA may include but are not limited to somnolence (780.09), fatigue (780.79), irritability (799.2) and headaches (784.0). Other signs of OSA include cognitive impairment, depression and personality changes. However, a psychiatrist or other qualified health professional may not have confirmed that the latter conditions require psychiatric ICD-9 diagnoses, which can reduce reimbursement and "tag" the patient with the insurer as having a psychiatric illness.

BiPAP Equipment Covered Through DMERC Policy

Physicians should also be aware of the coverage and certification of carrier guidelines when considering treatment of patients with home-based CPAP/BiPAP therapy, Pohlig says. Effective Jan. 12, 1987, Medicare issued a national coverage determination that covered CPAP (K0532) for adult patients with moderate or severe OSA for whom surgery is a likely alternative. Since that decision specifically addressed CPAP only, the durable medical equipment regional carriers (DMERCs) have issued a respiratory-assist-devices regional medical review policy that addresses BiPAP devices and other accessories, which was last revised in 1999. While physicians don't bill these codes (the DME supplier does), the physician has to certify that the patient has the condition warranting BiPAP.
 
CMS says a respiratory-assist device with bilevel pressure capability, without backup rate feature, used with noninvasive interface (K0532) is covered for the first three months of noninvasive positive pressure respiratory assistance (NPPRA) for the treatment of OSA, if the following criteria are met:

  • A complete facility-based, attended polysomnogram has established the diagnosis of obstructive sleep apnea. 
         
  • A single-level device (E0601, CPAP) has been tried and proven ineffective.

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