Pulmonology Coding Alert

Experts explain why you can't unbundle 94660 and 99293 If you've been reporting ventilation management services (94660-94662) with pediatric critical care codes (99293-99294), expect the denials to start rolling in.
 
Thanks to the National Correct Coding Initiative (NCCI) version 9.3 edits, which took effect Oct. 1, you won't be able to bill 94660 and 99293, coding experts say Report Critical Care Without Modifier -59 Typically, coders avoid reporting ventilation management and E/M codes together. Standard CPT, Medicare and NCCI policy bundles 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management]) and 94662 (Continuous negative pressure ventilation [CNP], initiation and management) into most E/M codes, such as 99213 (Office or other outpatient visit ... established patient ...), and doesn't allow coders to use modifier -59 (Distinct procedural service) to unbundle the services, says Anthony M. Marinelli, MD, FCCP, chairman of the American Thoracic Society's Clinical Practice Committee in Oak Park, Ill.
 
Therefore, if the physician performs an E/M service and a ventilation management treatment on the same patient on the same day, you would report either the E/M code or 94660 or 94662, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.
 
But this year, CPT created two new critical care codes, 99293 (Initial pediatric critical care, 31 days up through 24 months of age, per day ...) and 99294 (Subsequent pediatric critical care ...), so CMS had not specifically bundled 94660 and 94662 into these pediatric critical care codes until NCCI, version 9.3. Therefore, prior to these NCCI edits, a coder could have submitted a claim for both 99293 and 94660 (CPAP), although Medicare probably would have denied the claim, Pohlig says.
 
For example, your pulmonologist exams a 15-day-old infant with respiratory distress (786.09), and diagnoses respiratory distress syndrome (769). He uses continuous positive airway pressure ventilation (CPAP, 94660) to treat the disorder. Before NCCI 9.3, you might have been tempted to submit both 99295 (Initial neonatal critical care ...) and 94660 for your physician's services. Now, CMS plainly forbids that practice and gives the edit a status indicator of 0, which means under no circumstances can you attach modifier -59 to unbundle the codes, Marinelli says.

Watch Out for These E/M Services

 Medicare also bundled ventilation management services (94660-94662) into other evaluation and management codes. These include:
   99217 - Observation care discharge
   99218 - Initial observation care
   99281 - Emergency department visit
   99295 - Initial neonatal critical care ... 30 days of age or less
   99296 - Subsequent neonatal critical care ...
   99298 - Subsequent intensive care ... recovering  very low birth weight infant (present body weight less than 1500 grams)
   99299 - ... recovering low birth weight infant (present body weight of [...]