Pulmonology Coding Alert

Question: Our pulmonology practice recently received a cardiology referral who has symptomatic sinus bradycardia and possible obstructive sleep apnea (OSA). If we perform a sleep study in our lab, what should we record as the underlying diagnosis? How should we bill the consultative service? If we initiate continuous positive airway pressure (CPAP), how should this service be coded?

Tennessee Subscriber

Answer: The first patient encounter resulted from a referral to your physician for his or her medical opinion. The provider would bill this service reporting the patient's diagnosis, if definitive, and any symptoms/conditions that would impact this patient's care. If a definitive diagnosis cannot be reached, the symptoms are reported as the primary diagnosis. Document and report the standard consultation (99241-99245) for this service.

If the cardiologist requests a sleep study, the medical necessity for the procedure may be documented in several ways. Physicians should report the diagnosis determined after the study has been performed. If the study does not confirm the presence of a sleep disturbance, report the symptoms that precipitated the performance of the sleep study. Depending on the type of study performed, CPAP may be initiated during the study. You should note that when Medicare is the carrier, CPAP initiation is bundled into the sleep study when both services are provided on the same date of service. CPAP cannot be unbundled from the sleep study unless the physician has a reason that is unrelated to that for performing the sleep study.

After the physician interprets the sleep study, the patient returns to the physician's office to discuss the test results and review the plan of care. If the CPAP was not initiated during the sleep study and it is warranted, the pulmonologist would most likely discuss the initiation of CPAP with the patient during this encounter. Bill either CPAP (94660) if it is initiated by the physician in the office, or an office visit, which includes the CPAP (99212 or 99213). If CPAP was the only service provided, bill 99212. But 94660 and 99212 or 99213 cannot be billed on the same day. If CPAP is initiated at home, it cannot be reported as part of an office visit.

Note: CMS recently announced a review of the current national coverage policy for CPAP for the treatment of OSA. Consequently, the agency published a new coverage determination Oct. 31, 2001; however, a new policy describing changes has not been issued.