Pulmonology Coding Alert

Question: We are billing a recurring office visit code (99211"99215) with 94660 on the same day, but we are getting denied. On the other hand, when we bill 94660 independently, we get our reimbursement without any hassle. What are we doing wrong?

Colorado Subscriber

Answer: To bill for 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management), 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 when another health care provider performs it.

Important: You should use 94660 for the initiation and management of CPAP therapy. You bill this code when the treatment is initiated with the patient, in order to describe the initiation and instruction of 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.

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.

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, report 94660 under the NPP's name (as permitted by the State Scope of Practice).