Internists need to know coding for CPAP, observation services

ACP often receives inquiries that fall outside the typical boundaries of primary care. Understanding that there is more to internal medicine than the usual evaluation and management services, this month's column focuses on two less common services: CPAP and observation services.

Q: I am an internist who orders and reviews many sleep studies. If a patient has sleep apnea, I order a titration study, and then order home continuous positive airway pressure ventilation (CPAP), initiation and management equipment. Once I have the test results, I coordinate and supervise use of it. Is CPT 94660 the correct code to use?

A: Your scenario describes the post-service evaluation and management care, not actually CPT 94660.

CPT code 94660 is a face-to-face service addressing the use of CPAP for sleep-disordered breathing, such as (but not limited to) obstructive sleep apnea. This may often be performed in a sleep testing laboratory. CPT code 94660 requires that the physician personally perform face-to-face patient care, such as fitting the mask and titrating pressure. There is respiratory therapist work and practice expense, in addition to the physician's phoning in orders and signing forms.

Payment for the service is bundled (through the Correct Coding Initiative edits) into all the other evaluation and management services, including critical care. The equipment costs are not built into the reimbursement for CPT 94660, because patients can use their own.

In the outpatient setting, an E/M service such as 99213 or 99214 is usually a more appropriate code. In the inpatient setting, either ventilator management services (CPT 94003) or a hospital visit code (CPT 99232) is typically a better representation of the services. In a limited circumstance, where little history, examination, or other issues are addressed, the 94660 code is appropriate.

Q: I have questions about the correct use of the CPT codes for observation with same-day discharge services (99234-99236). This is a typical scenario for us: A patient is admitted to the hospital through the emergency department at 10 p.m. on Jan. 1. The physician examines and evaluates the patient at 8 a.m. on the following day, Jan. 2. Then, the physician returns and discharges the patient at 6 p.m. on January 2. Our compliance office tells us that we cannot use CPT 99234 in this type of situation because of the different calendar dates of admission and discharge. I contend that the physician involvement is on the “same calendar date of service” and as such, meets the Centers for Medicare and Medicaid Services' requirements, and that the most appropriate code is among the CPT 99234-99236 range. What does ACP advise?

A: There are (at least) two different sets of guidance on billing: one from CPT, and the other from CMS. But they both agree that when a patient is admitted on one date and then discharged on the next date, CPT codes 99234-99236 do not apply. The key is the date(s) of admission and discharge, but not (perhaps counterintuitively) when the patient was seen by the physician.

According to the CPT coding guidelines, observation with same-day discharge services codes 99234-99236 are used when the patient is admitted and discharged on the same date of service. If the patient is admitted on Jan. 1, but discharged on Jan. 2 (two calendar dates), these codes do not apply. CPT codes 99234-99236 apply only if the patient is/was in observation status during their hospital visit.

Under Medicare's coding rules (derived from Medicare's billing guidance for inpatient hospital services), when a patient is admitted to inpatient hospital care for fewer than eight hours on the same calendar date, you must report the initial hospital care using a code from CPT code range 99221-99223. In this scenario, do not use the hospital discharge day management service (CPT code 99238 or 99239).

When a patient is admitted for inpatient hospital care and discharged on a different calendar date, you must report the initial hospital care using a code from CPT code range 99221-99223, and the hospital discharge day management service (CPT code 99238 or 99239).

However, when a patient is admitted to inpatient hospital care for a minimum of eight hours but less than 24 hours and discharged on the same calendar date, you must report the observation or inpatient hospital care services (including admission and discharge services on the same day) using a code from CPT code range 99234-99236, and no additional discharge service.

Remember that your medical record documentation must meet the evaluation and management documentation requirements for history, examination and medical decision making.