Pulmonology Coding Alert

Respiratory care departments: New codes 94644-94645 also apply to you

Your ventilator coding just got easier thanks to CPT 2007's creation of four site-specific management codes.

But that's not all. Pulmonary medicine coders will have their hands full learning the nuances of 13 new codes. "Ventilator management has the greatest impact as the old (payable) ones have been replaced with new (payable) ones," says Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "Some of the other services may capture additional work but on a more limited basis." 

The AMA splits the pulmonary sub-section of CPT's Medicine section into two sub-subsections for "ventilator management" and "other procedures." New pulmonary codes will be added for site-specific ventilator management, surfactant administration, continuous bronchodilator inhalation and pediatric home apnea monitoring. This overhaul is coupled by a new code for tumor ablation therapy.

Don't worry: Experts share the rationale on these changes and give you the details you need to start using these codes this winter.
 
Follow 2 Rules When Coding Ventilator Mgt CPO

CPT 2007 will also provide you with a way to code home ventilator management.

New monthly CPO code: For each month of 30 minutes or more of home ventilator management care plan oversight (CPO), you will be able to report 94005, which includes:

• review of status

• review of laboratories and other studies

• revision of orders and respiratory care plan (as appropriate).

When using 94005 (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), remember these rules:

Rule 1: Don't report this service when performed by the same physician/group along with other home (99339-99340) or home health agency, hospice or nursing facility (99374-99378) CPO services, according to the parenthetical instruction following 94005 in the CPT 2007 manual.

Rule 2: You can still use 94005 when another physician concurrently provides CPO during the same period.

Downside: Medicare has not deemed this as an allowable, reimbursable service as of yet.

Base Daily Vent Code on POS, Day

For ventilator management in the hospital or nursing facility, you should use new codes 94002-94004, which replace deleted codes 94656 and 94657. The pulmonary medicine specialty societies requested a relative value unit change to 94657, notes CMS in the proposed notice on the work relative value units five-year review. But the Relative Update Committee (RUC) "determined that a rank order anomaly would be created with 94656 if the recommended value for CPT code 94657 was adopted," according to page 106 of CMS-1512-PN.

Problem with 94657: "There was some confusion as to whether this code applied only to hospitalized patients, to patients in nursing homes; or to both," writes Alan Plummer, MD in "the Effects of the RUC Five-Year Review on Pulmonary and Internal Medicine" published in U.S. Respiratory Disease 2006. Because of the lack of clarity, the matter was referred to the CPT Committee for review."

How you benefit: CPT 2007 offers clearer ventilator codes. The CPT Editorial Panel examined the code and created a new sub-section containing new site-specific codes, rather than revising existing "initial" and "subsequent-day" hospital-based codes 94656 and 94657.

New method: Choose the appropriate daily ventilation management code, which describes "ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing," based on the place of service (POS) and performance day as follows:

Caveat: Do not report ventilation management codes in addition to critical care services (99289-99299). When you provide both services, code only for the critical care service.

Report Inhalation Based on Time

Make sure to add two new continuous bronchodilator codes to your encounter sheet. The new codes, which can be used in hospital respiratory care departments, "will benefit the pulmonary community," says Plummer, who is also professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. "The modality has been proven to be effective and safe for patients."

The basics: "The continuous bronchodilator codes have no physician work, but do have practice expense," Plummer points out. Because no codes existed for continuous bronchodilator administration, the American Thoracic Society (ATS) and the American College of Chest Physicians (ACCP) petitioned CPT for these codes.

You should assign these codes based on the total treatment time. So chart notes that clearly indicate treat-ment time are crucial.

Do this: For the first hour of treatment, report 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour). Then code each additional hour with 94645 (... each additional hour [list separately in addition to code for primary procedure]).

Denials avoided: Never report 94645 as the only continuous inhalation treatment code. Code 94645 is an add-on code that you must "use in conjunction with 94644," stipulates the parenthetical directive following the 94645.

Pitfall: Great as the new codes are, their benefits may not be as clear cut. "Continuous inhalation requires additional time and effort that may not be feasible in the outpatient setting," Pohlig notes. The service will not be reported when performed in a hospital setting.

Report Ablation Therapy With 32998

The respiratory system gains one new code in CPT 2007. The AMA deleted 31700, 31708 and 31710 and added this code:

• 32998 -- Ablation therapy for reduction or eradication of one or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral 
 
RFA of the lung is an emerging treatment, Pohlig says. "Prior to establishment of the new code, there was no efficient or consistent way of reporting this service." 

Don't overlook: If the pulmonologist uses imaging guidance and monitoring to perform ablation therapy, you should also report revised code:

• 76940 -- Ultrasound guidance for, and monitoring of, parenchymal tissue albation

• 77013 -- Computerized tomography guidance for, and monitoring of, parenchymal tissue albation

• 77022 -- Magnetic resonance guidance for, and monitoring of, parenchymal tissue albation.

Append the appropriate guidance code with modifier 26 (Professional component) to bill for the physician service only.

Use 94774/7 for Apnea Monitoring

Although CPT 2007 will create four home apnea monitoring codes, only one of these codes apply to physicians, says Jill M. Young, CPC-EDS, president of Young Medical Consulting, LLC in East Lansing, Mich. "Home health agencies (HHAs) will use the other two codes, which involve no physician work."

New code for initial setup: When you first decide that a patient requires home monitoring, consider your coding options. The "global" code (94774) encompasses several elements. According to CPT Changes: An Insider's View 2007, the physician:

• orders home monitoring

• chooses the monitor limits

• arranges for a home care provider to meet with the parents

• the monitor is attached

• the information is downloaded to a computer which complies the data

• the physician interprets data supplied by the HHA monthly or after any significant home apnea episode and prepares a report.

Important: Physicians may only report this global code if he or his staff provides all elements involved.

New code for periodic review: If the HHA provides the setup and transmission, the pulmonologist should only report his involvement: the interpretation. From the HHA, the pediatric pulmonologist will periodically receive downloaded information in hard copy or CD form, which he or she interprets and issues a report on. The report includes recommendations on continuing or discontinuing of the monitoring. Code 94777 describes the "physician review, interpretation and preparation of report only."

Keep in mind: Don't interpret 94777 to mean the pediatric pulmonologist has to relay the information contained in the report to the patient. The physician could "send the report back to the primary care provider for the PCP to discuss with the patient and family," Young says. Alternatively, the interpreting physician (who is taking care of the patient) could speak with the family.

Report 94610 for Surfactant

You will soon have a code for surfactant administration performed in a delivery room or outlying hospital prior to patient transfer.

When a local care team provides the initial installation of surfactant prior to the transport of a neonate to the regional nursery, assign 94610 (Intrapulmonary surfactant administration by a physician through endotracheal tube). "Surfactant can be given in hospital and delivery room and on transport," says Richard A. Molteni, MD, FAAP, medical director at Children's Hospital and Regional Medical Center in Seattle.

Warning: CPT 2007 indicates you should not report 94610 in addition to pediatric and neonatal critical care services (99293-99296). "Code 94610 can be added to transport and non-critical care services reported on the same day," Molteni says.