Pulmonology Coding Alert

Question: Our pulmonologist recently provided E/M services and also performed ventilation using CPAP. Can we bill the E/M services with the CPAP therapy? We tried doing this but we got denied. What codes should we report when our pulmonologist provides these services together?

Houston Subscriber

Answer: You should use 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management) for the initiation and management of CPAP therapy. You bill this code when the treatment is initiated, in order to describe the initiation and instruction to the patient. If the patient returns and requires additional instruction on use or other issues related to the use of the CPAP device, you should report this service once again.

To bill for 94660, the physician must provide a face-to-face encounter with the patient. Since this is not a time-based service, it doesn’t require physician presence in the room throughout the entire time the patient is in the office. However, it is not an “incident-to” service, which means you cannot report it under the physician NPI when another health care provider performs it.

Exception to the rule: If, on those occasions, a separately identifiable service occurs (i.e., the physician does not spend the visit solely for management of the patient’s use of the CPAP machine), then you should bill either a level of office visit or 94660, whichever involves the most time and focus of the visit. CCI bundles 94660 into E/M services without the ability to separately report these two services.

So, in your case scenario, since both an E/M service and ventilation management services were provided, you’ll only bill the E/M services for the session. If you bill both the services together, your claim for 94660 will be denied.

Careful: Do not ever bill 94660 on a routine basis, such as monthly or even quarterly. Report the code when only when the patient’s need warrants it. If the service is provided to a Medicare beneficiary by a nonphysician provider in the physician’s office(as permitted by the State Scope of Practice), report 94660 under the NPP’s name.