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Pulmonology Coding Alert

NCCI 9.3 Update:

Are You Reporting Ventilation Management and Critical Care Together? Not Anymore

Published on Sun Oct 12, 2003

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 1500-2500 grams).

    As with pediatric critical care codes, any of the above E/M services your pulmonologist provides include ventilation management. Furthermore, under no circumstances can you unbundle the codes.

    Unbundling Unlikely With 95024 and 95028

    NCCI made sure that coders wouldn't report some ultrasonic codes with several allergy-related codes without proving the physician provided separate services to the same patient, on the same day.
     
    The following codes carry a status "1" indicator, which means that you may unbundle the codes with modifier -59 if your physician's documentation proves that he or she performed the services separately, Pohlig says.

     

  •  CMS now considers 76001 (Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy]) an integral part of ultrasonic guidance with needle placement (76942, Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) when the pulmonologist performs the services on the same patient, on the same day. Typically, you may report these codes for your pulmonologist's transbronchial biopsy services (31628, Bronchoscopy [rigid or flexible]; with transbronchial lung biopsy, with or without fluoroscopic guidance).

     
  •  Don't report 95024 (Intracutaneous [intradermal] tests with allergenic extracts, immediate type reaction, specify number of tests) in addition to 95028 (Intracutaneous [intradermal] tests with allergenic extracts, delayed type reaction, including reading, specify number of tests) unless your pulmonologist's documentation supports modifier -59 usage - which it probably will not, Pohlig says.
     
    Most likely your physician will not separately use both an immediate and delayed allergy test on the same patient, on the same day, she adds.

     
  •  Also, you should avoid billing separately for 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]) and 95144 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single dose vial[s] [specify number of vials]) even though NCCI assigns the bundling edit a modifier -59. That's because both 95165 and 95144 represent similar services, and insurers might be skeptical if a physician claimed that he or she used such similar treatments for separate purposes, Pohlig says.

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