Pulmonology Coding Alert

Question: Our pulmonologist recently attended to an established patient with anxiety, breathlessness, and sleep apnea in our office. She documented that she performed a routine exam (BP etc.) and CPAP management. How should I code this encounter? Can I bill an E/M such as 99211 when this procedure is performed in physician office?

Missouri Subscriber

Answer: You should report 94660 (Continuous positive airway pressure [CPAP] ventilation, initiation and management) for the CPAP (continuous positive airway pressure ventilation) provided by your physician. Although CCI bundles 94660 into E/M services, you may bill an E/M code with code 94660 as the E/M code has a column B indicator “1,” which means you may use the code with a modifier. You have just to ensure that the provider or nurse rendering service performed the minimal level of a medically necessary E/M service like examining the blood pressure of the patient because the patient complained of a headache and feeling flush. According to your information, you demonstrate the evaluation, but not the management of the “problem.” Therefore, you may not report 99211 (Office or other outpatient visit for the evaluation and management of an established patient,…) for a nurse visit or any other physician E/M service (e.g., 99212). If the additional E/M were supported, you would attach modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) to the E/M code to indicate that the E/M service was separate from the CPAP service provided. However, you have to make sure that the document clearly supports modifier 25 by documenting the separately identifiable service that occurred (i.e., the physician does not spend the visit solely for management of the patient’s use of the CPAP machine).

Check your documentation to verify that:

• The physician provided 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.

• The pulmonologist initiated and managed the CPAP ventilation. You should not bill 94660 when the pulmonologist just checks the pressure on a patient’s CPAP machine, and another therapist or NPP has initiated the CPAP.