Itamar Medical Coding and Reimbursement

Transcription

1 Itamar Medical Coding and Reimbursement WatchPAT Home Sleep Apnea Testing (HSAT) Frequently Asked Questions DISCLAIMER: The information contained in this guide is provided to assist you in understanding the reimbursement process. It is intended to assist providers in accurately obtaining reimbursement for health care services. It is not intended to increase or maximize reimbursement by any payer. We strongly suggest that you consult your payer organization with regard to local reimbursement policies. The information contained in this document is provided for information purposes only and represents no statement, promise or guarantee by Itamar Medical concerning levels of reimbursement, payment or charge. Similarly, all CPT and HCPCS codes are supplied for information purposes only and represent no statement, promise or guarantee by Itamar Medical that these codes will be appropriate or that reimbursement will be made.

2 Table of Contents SECTION PAGE PATIENT SELECTION CRITERIA 3 CODING & MODIFIERS 4 PLACE OF SERVICE 7 PAYMENT FREQUENCY 7 ACCREDITATION 8 MEDICARE RULES AND REGULATIONS FOR TREATMENT 8 CPAP TITRATION AND EFFECTIVENESS TESTING 9 SLEEP MEDICINE GLOSSARY AND ACRONYMS 10 CODING RESOURCES AND REFERENCES 11 2

3 PATIENT SELECTION CRITERIA Q. Who is a candidate for a WatchPAT Home Sleep Apnea Testing (HSAT)? A. HSAT is intended for patients who exhibit clinical symptoms of Obstructive Sleep Apnea (OSA). Patients with other sleep disorders (i.e. Restless Leg Syndrome (RLS), narcolepsy, REM-behavior disorder), co-morbid conditions (which may impact the diagnostic relevance of the SaO2 data such as COPD), and patients in whom you only mildly suspect sleep apnea are not candidates for HSAT. Patients with hypertension or diabetes are candidates, as are those that exhibit symptoms of apnea. Loud snoring Witnessed apnea events Excessive daytime sleepiness Morning headaches History of high blood pressure Memory problems or poor judgment OSA Symptoms include the following: Depression Gastroesophageal reflux Impotence Nocturia Difficulty concentrating Personality changes or irritability Q. Does Medicare require a comprehensive clinical evaluation? A. Yes. Medicare states that a home sleep test is covered only when it is performed in conjunction with a comprehensive sleep evaluation and in patients with a high pretest probability of moderate to severe obstructive sleep apnea. Q. What does a comprehensive clinical evaluation entail? A. Determine if a patient is at risk for Obstructive Sleep Apnea (OSA). 1. Ask the patient to complete the Epworth Sleepiness Scale or Stop-Bang Questionnaire. The OSA screening include a review of common risk factors such as: Does the patient snore? Is the patient excessively tired during the day? Has the patient been told they stop breathing during sleep? Does the patient have hypertension? Is the patients neck size greater than 17 inches (male) or 16 inches (female)? If the patient answers yes to at least two questions they are a candidate for HSAT. 2. Perform a cardiopulmonary assessment to rule out exclusionary disorders such as COPD. Examine the upper respiratory airway looking for enlarged tonsils, obvious asymmetries or blockage of the nasal passages and document all findings in the patient s chart. Q. What is The Epworth Sleepiness Scale? A. This is a questionnaire used to determine the level of daytime sleepiness. A score of 11 or more is accepted by most payers to justify reimbursement for HSAT. Q. What is the STOP - BANG questionnaire? A. Alternative to the Epworth questionnaire, other evaluation tools may be employed for initial OSA assessment. These tools include STOP-BANG. The STOP portion of the questionnaire (Snore, Tired, Obstruction, Pressure) is a 4 question tool that provides a quick guide for diagnosis. Patients tend to have a low risk of OSA if the answers are affirmative to 1 or less, and a moderate to high risk of Sleep Disordered Breathing (SDB) if the answers are affirmative to 2 or more questions. The BANG portion of the questionnaire (BMI, Age, Neck, Gender) identifies patients that tend to have a low risk of OSA if there is only 1, or zero, affirmative answer. Affirmative answers to 3 or more of the combined STOP-BANG questions indicate a moderate to high risk of OSA and are candidates for HSAT. 3

4 CODING & MODIFIERS Procedure Coding CPT Code Description Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time G0400 Home sleep test (hst) with type IV portable monitor, unattended; minimum of 3 channels Q. What CPT / HCPCS code is used to bill the WatchPAT home sleep study? A. Different insurers accept different codes for HSAT. Some insurers accept the HCPCS G-code (G0400), while others accept the CPT codes for WatchPAT HSAT (95800). Still other insurers accept both the G-code and the CPT code. An HSAT provider will need to contact each insurer they work with to identify which codes can be reported. Q: What codes are used if the physician provides the WatchPAT as a global service (i.e., patient obtains equipment, goes home and brings back for interpretation)? A: Depending on the payer the provider will bill either CPT or HCPCS G0400 without a modifier, indicating that the physician performed both the technical and professional component. Contact your Medicare contractor or other payer to determine if you meet their requirements for billing globally. Q: Are office visits and HSAT done the same day billed separately? A: Payers vary in coverage eligibility for E&M services when billed on the same day as diagnostic testing. Always confirm same day billing with the payer. Medicare does not cover a E&M visit on the same date of service the HSAT is billed, unless it is for a separate and distinct service. When billing Medicare refer to the National Correct Coding Initiative (CCI) website tables to determine if Column 2 codes can be unbundled from Column 1 codes on the same day of service. Q. How do I code for a patient office visit? Can I use consultation codes? What diagnosis code is appropriate for a patient office visit during which the patient is evaluated for OSA and scheduled for testing? A. Patient visits are billed using evaluation and management (E/M) codes. The E/M codes are found in the CPT code book. Office visits in particular are billed using two code ranges for new patients, E/M codes can be used; for established patients, E/M codes can be used. Medicare no longer reimburses for consultation codes (E/M code range However some private payers may still reimburse for these services. Q. What codes are required to bill Medicare for outpatient hospital HSAT? A. Hospital outpatients will code the technical component of HSAT under APC Ambulatory Payment Classification (APC) codes are used by Medicare to reimburse facilities for the technical component under the Hospital Outpatient Prospective Payment System (OPPS). CMS assigned the Ambulatory Payment Classification (APC) group 0213 to various unattended sleep studies. The codes classified under APC 0213 are: 95800, and 95806, and G0398, G0399, and G0400. Q. How do third party payers reimburse hospital outpatient facilities for the technical component of HSAT? A. Private insurers reimburse under alternatives from Medicare s APC payment method. Facilities are paid according to the type of contractual agreement between the insurer and the facility. In order to determine coverage and payment the facility should contact the payer directly. 4

5 Diagnosis Coding Commonly Used ICD-9-CM Diagnosis Codes for Symptoms and Signs of Sleep Apnea ICD-9 ICD-9-CM Diagnosis Code Description ICD-10 ICD-10-CM Diagnosis Code Description Insomnia with sleep apnea, unspecified G47.30 Sleep apnea, unspecified Hypersomnia with sleep apnea, unspecified G47.30 Sleep apnea, unspecified Unspecified sleep apnea G47.30 Sleep apnea, unspecified ICD-9-CM Diagnosis Code for the Confirmed Diagnosis of OSA ICD-9 ICD-9-CM Diagnosis Code Description ICD-10 ICD-10-CM Diagnosis Code Description Obstructive sleep apnea (adult)(pediatric) G47.33 Obstructive sleep apnea (adult)(pediatric) Q: Can you clarify if the first diagnosis is the reason for the test or the findings? A: The first diagnosis will be the reason for testing (the symptoms why the patient is considered a candidate for HSAT). For Medicare s covered list of diagnosis codes please refer to your Part B Medicare Administrator Contractor Sleep Studies Local Coverage Determination (LCD) policy. If a diagnosis is not established as a result of testing, the provider can code the patient s signs and symptoms that prompted you to perform the test. The provider cannot assign a patient a diagnosis that he/she does not have. The provider should document the evaluation of the patient as evidence that there was cause to run the test. Q. What is ICD-10? How and when will it affect sleep medicine? A. ICD-10 is the new manual for diagnostic coding. International Classification of Diseases, 10th Revision. ICD-10-CM replaced ICD-9-CM, Volumes 1 and 2 on October 1, Revisions in ICD-10 include: the addition of information relevant to ambulatory and managed care encounters; expanded injury codes; the creation of combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition; the addition of sixth and seventh characters; incorporation of common 4th and 5th digit sub-classifications; laterality; and greater specificity in code assignment. The new structure allows further expansion than was available with ICD-9-CM. Q. What are the commonly used diagnosis codes (ICD-9-CM & ICD-10-CM) commonly used for sleep apnea? A. Payers medical policies often list the eligible diagnosis codes for reporting of HSAT. Always refer to the medical policy or contact the payer directly to obtain a current copy of eligible diagnosis codes. An example of common codes is provided below but may not be recognized by all payers. Refer directly to the payer policy for further detail. For accurate reporting of diagnosis codes, the documentation should describe the patient s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. 5

6 Modifiers Examples of Commonly Used CPTÒ / HCPCS Modifiers Modifier Description -26 Professional Component: The professional component (PC) represents the supervision and interpretation of a procedure provided by the physician or other healthcare professional. It is identified by appending modifier 26 to the procedure code -TC Technical Component: Under certain circumstances, a charge may be made for the TC technical component alone. Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians. -52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Q. What CPT code modifiers are applicable to report WatchPAT? A. When a physician performs only the interpretation of a unattended sleep study the service is reported with the professional component (PC) modifier -26. When another provider or entity furnishes the equipment, application and instruction the service is reported with the technical component (TC) modifier -TC. Q: If the home study is incomplete (e.g. oxygen saturation period only lasted one hour and was inadequate for interpretation), can a provider use a 52 modifier for reduced services? A: Yes, append modifier 52 to the correct HCPCS code and make sure to reduce the billing. Q: What if the provider has a good study, but documents less than 6 hours of recording time? A: Any study fewer than 6 hours should be billed by appending modifier 52 and reduce the bill accordingly. Q: What if a patient takes home a device, but decides not to take the test? A: The medical record must document the medical reason the test was aborted. The provider in NOT eligible for payment if the patient decides not to undergo the test. Q: A sleep study test is stopped due to equipment failure. Can we bill the procedure using reduced services modifier -52? Or should we never bill discontinuation of a test due to equipment failure? A: The rule of thumb is that providers do not append modifier -52 to procedures involving equipment failure. The reduced services modifier references a physician s decision to discontinue a test/procedure due to extenuating medical circumstances. Generally this means patient safety and not equipment failure that prevents completion... however, Modifier -52 is typically used to code a limited service. For example, when a patient is intolerant to continuation of the sleep study before he or she completes six hours of recording, code the procedure Modifier -52 is designed for procedures that are halted due to a patient s condition or response to the test. While it is important to stop the test for patient safety resulting from equipment failure, this does not mean CMS or payers will reimburse for the partial test. CMS and payers rely upon the provider to maintain all equipment in good working order. Typically Providers absorb the costs associated with equipment failure. If providers choose to bill with reduced service modifier 52 for equipment failure the medical record must document this as the reason for the discontinuation and the payer will make an individual coverage decision. CMS and many third party payers will not recognize equipment failure for payment. 6

7 PLACE OF SERVICE Category Type Place of Service (POS) Code Non- Facility Physician Office 11 Non- Facility Home 12 Facility Outpatient Hospital 22 Q. What Place of Service (POS) codes do we use to bill the WatchPAT? A. According to Medicare regulations the POS code shall be assigned as the same setting in which the beneficiary received face-to-face services. In cases where the face-to-face requirement is eliminated (such as those when a provider performs the professional component/interpretation of a diagnostic test from a distant site) as a general policy, the POS code assigned by the physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary received the TC service. (Some Medicare contractors (e.g., WPS) Local Coverage Decisions (LCDs) may differ on their HSAT POS designation. Please clarify POS codes with your local Contractor) a) Face to face instructions and provision of the device are provided in an office setting with interpretations performed in an office setting. Both the technical and professional component are billed with POS (11) office. b) If the HSAT is shipped to the patient at home with a follow up call to overview instructions the POS (12) is used to bill the technical component. The report is sent to the physician and is interpreted in the office setting with a POS (11) assigned to the interpretation. c) In the case of an Independent Diagnostic Testing Facility (IDTF), the situation would be the same as above in b) Q. What POS code is used to bill the technical component of HSAT performed by an outpatient hospital? A. POS code 22 is reported for services rendered by an outpatient hospital facility. FREQUENCY Q: Is there a limit to how many sleep studies a Medicare beneficiary may have? A: Medicare does not expect to see no more than 2 per year, however, there is no specific limit regulated. Each test must be proven to be reasonable and necessary. Generally, an initial diagnostic HSAT should be all that is needed for several months, unless there is an extraordinary change in the patients well being. Q: How often can HSAT be performed and qualify for third party payer reimbursement? A. Payers vary on the number of sleep studies that are considered medically necessary per year. Payers will cover HSAT when it is medically necessary to repeat a study (i.e., technical failure) or if a re-evaluation is needed. It is recommended to review the respective payer medical policy and in some cases to seek a prior authorization. Q. How many consecutive nights of study can I perform and be reimbursed? A. Medicare and many third party payers state that if you perform two or three nights of study it will only be reimbursed as one night of study. However, more than one night of study may be covered if medical necessity is established, or as outlined under provider and payer contract arrangements. 7

8 ACCREDITATION Medical Physicians Q. Does Medicare and third party payers have any restriction on who can bill for HST? A. Yes. All Medicare Contractors require that the physician who interprets the sleep study has a sleep certification issued by specific Specialty Boards or is an active member of an accredited sleep center or laboratory. Medicare also restricts Durable Medical Equipment Suppliers from providing any component of sleep testing. Third party payers make autonomous decisions in the development of their medical policies and the limitations they set. While some third party payers include sleep certification or accreditation requirements for HST in their policies most do not. Check payer policies for applicable limitations. Q. Who can interpret HSAT? What are the requirements for physicians interpreting HSAT in a different state than the state where the test was performed? A. State licensure requirements vary from state to state. However, in most states it is required that a physician interpreting a test hold a medical license in the state in which the test was performed. In the case of HSAT, in most cases the physician interpreting the test will be required to hold a license in the state where the patient was tested. Q. If a physician is eligible to sit for the sleep medicine board certification exam can he/she interpret sleep studies and obtain reimbursement? A. Requirements for interpretation of sleep studies vary from insurer to insurer. Some payers do allow board eligible physicians to interpret studies without being over-read by a board certified physician. Physicians without board certification in sleep medicine should check with each insurance provider they work with to determine if they can interpret sleep studies without being over read. Q: Can we subcontract with a provider from a different state to perform the home sleep test setups, even though they are not a Medicare provider? Would we bill since we are the contracted provider? A: No, the subcontracted provider setting up the technical portion, must be enrolled with their respective Medicare Administrative Contractor (MAC) and bill their state to be paid correctly in their locality. Q: How do we bill when a separate contracted provider does the interpretation? Do we split with a technical (TC) and professional (26)? A: Yes, as each provider must reflect their address in Item 32. Example: Separate Interpretation No Global POS CPT /Modifier Technical (IDTF-Denver, CO) TC Professional (Dr. Jones-Seattle, WA) Dentists Q: Are dentist allowed to order diagnostic tests for sleep apnea? Can dentists order home sleep studies as well? A: Whether or not a dentist is legally permitted to order a home sleep study depends on the scope of the practice of dentistry under state law. Each state has a statute that specifically defines the scope of dental practice. Dentists are advised to review their state statutes or contact their State Board of Examiners. MEDICARE RULES AND REGULATIONS FOR TREATMENT Q: If the sleep study is denied, is the CPAP not covered? A: Payment for the sleep study is unrelated to payment for the CPAP. The DME MAC would evaluate the criteria found in the sleep study to determine coverage for the PAP device prescribed. 8

9 Q: Can the face-to-face visit prior to the sleep study be performed by a treating physician that is different than the one that prescribes the PAP? A: Yes. CMS clarified that the face-to-face physician can be different than the physician who prescribes PAP therapy; the physician who is considered to be the Written Order Prior to Delivery (WOPD) physician. Q: Is it a requirement that the patient have two face to face visits 1) before the sleep study and 2) before receiving a prescription for CPAP? A: No, however it could become necessary. A face-to-face visit is required prior to the sleep study per the LCD. If greater than 6 months elapses from that face-to-face prior to prescription for PAP, another face-to-face visit would be necessary to meet the ACA Section 6407 requirements of a visit within 6 months of the order. Q: Does the face-to-face and pap device have to be within 3 or 6 months of the sleep study? A: A face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved (reevaluation occurs no sooner than the 31st day, but no later than the 91st day after initiating therapy. Q. Is there a CPT code for home auto-titration? If not, how do I code for this service? A. There is currently no specific CPT/HCPCS code for home auto-titration. The physician can bill for the APAP device using the DME code E0601. However, this code only captures the device itself and not the work done to titrate the patient. Review and interpretation of the APAP download and use of this information to determine a fixed pressure for the patient can be billed as a part of the evaluation and management (E/M) service ( , ) the physician provides. Because of the amount of data reviewed, a higher level of medical decision may be made. CPAP TITRATION AND EFFECTIVENESS TESTING Q. Is CPAP titration and effectiveness with a Home Sleep Test covered? How many times a year can a patient be retested with a WP? A. Payers develop their own policies and guidelines regarding what is and what is not considered eligible for coverage. Below is an excerpt from Aetna s policy on this subject. Aetna Policy Excerpt (Policy # 0004 Source: It may be necessary to perform repeat sleep studies up to twice a year for any of the following indications (Note: where repeat testing is indicated, attended full-channel nocturnal polysomnography (NPSG) (Type I device) performed in a healthcare facility is considered medically necessary for persons who meet criteria for attended NPSG in section I above; in all other cases, unattended (home) sleep studies are considered medically necessary): To determine whether positive airway pressure treatment (i.e., CPAP, bilevel positive airway pressure (BiPAP), demand positive airway pressure (DPAP), variable positive airway pressure (VPAP), or auto-titrating positive airway pressure (AutoPAP)) continues to be effective; or To determine whether positive airway pressure treatment settings need to be changed; or To determine whether continued treatment with positive airway pressure treatment is necessary; or To assess treatment response after upper airway surgical procedures and after initial treatment with oral appliances Note: A home sleep study is performed over multiple nights with a single interpretation is considered a single sleep study for purposes of reimbursement. 9

10 SLEEP MEDICINE GLOSSARY AND ACRONYMS Abbreviations AAI AHI AHRQ ASDA ARI AASM AUC CER CHF CI CMS Services COPD CPAP CSB CTAF Forum ECG EEG EMG EOG ESS FDA h HR HST ICC LSAT autonomic arousal index Apnea-Hypopnea Index Agency for Healthcare Research and Quality s American Sleep Disorders Association American Sleep Disorders Association-based arousal index American Academy of Sleep Medicine area under the curve comparative effectiveness review congestive heart failure confidence interval Centers for Medicare and Medicaid chronic obstructive pulmonary disease continuous positive airway pressure Cheyne-Stokes breathing California Technology Assessment electrocardiogram electroencephalogram electromyogram electrooculogram Epworth sleepiness scale Food and Drug Administration hour heart rate home sleep testing intraclass correlation coefficient lowest oxygen saturation MAD Mandibular Advancement Devices NA not applicable NREM non-rapid eye movement NS non-significant ODI oxygen desaturation index OOC out-of-center OSA obstructive sleep apnea PAT peripheral arterial tone PAT-AAI peripheral arterial tone-based autonomic arousal index PSG polysomnography pt patient r correlation RDI Respiratory Disturbances Index REM rapid eye movement RERA Respiratory Effort Related Arousal ROC receiver operator characteristics SCOPER Sleep, Cardiovascular, Oximetry, Position, Effort and Respiratory SRBD sleep-related breathing disorders SMD standardized mean difference TST true sleep time TRT total recording time US United States vs versus w/ with WP100 WatchPAT 100 WP200 WatchPAT 200 Definitions TERM Apnea-Hypopnea Index (AHI) Arousal Index (AI) Epoch Oxygen Desaturation Index (ODI) Respiratory Disturbances Index (RDI) Respiratory Effort Related Arousal (RERA) Sleep-related breathing disorders DEFINITION Index used to indicate the severity of sleep apnea; represented by the number of apnea and hypopnea events per hour of sleep Index used to indicate the number of arousals per hour of sleep (measure of sleep fragmentation) 30-second time segment used in sleep scoring Index used to indicate the number of arterial blood oxygen desaturations per hour of sleep Index used to indicate the severity of sleep apnea; represented by the number of apnea, hypopnea and RERA events per hour of sleep A sleep arousal event that is associated with respiratory effort A general term for all types of sleep apnea 10

11 CODING RESOURCES AND REFERENCES Itamar Medical Resources: Reimbursement materials may be found at: /Medical_Professional/Insurance_Reimbursement For additional questions, contact: Other Resources: AASM (American Academy of Sleep Medicine) American Medical Association: Current Procedural Terminology (CPT ), Professional Edition, 2015 American Medical Association (AMA). All Rights Reserved CPT Network: An online, subscription-based service for coding information: CPT Assistant: A monthly coding publication of the American Medical Association American Medical Association ICD-10-CM 2016 Standard, Complete Official Codebook. AMA 2015 ( ICD-10-PCS 2016 Standard, Complete Official Codebook. AMA 2015 ( Medicare Program website: 11