Pediatric Home Apnea Monitors* Coding, Billing, and Updated Prescribing Information for Practice Management

CHEST Topics in Practice Management Pediatric Home Apnea Monitors* Coding, Billing, and Updated Prescribing Information for Practice Management Ann C. Halbower, MD A series of new current procedural terminology codes have been created that allow health-care providers to code and bill for pediatric home apnea monitoring in the United States. Apnea monitors have been used at home on pediatric patients at risk for sudden death for > 30 years without the benefit of evidence-based efficacy studies. Nevertheless, new apnea monitor devices with expanded capability have been developed. Recommended indications for pediatric home apnea monitors are outdated and vague. It is important for the prescribing health-care provider to understand device function, as well as the pathophysiology of cardiorespiratory events in different disease states in order to make logical decisions about which monitor to prescribe, or whether to prescribe one at all. This article will review what apnea monitors are designed to do, common misperceptions about device indications vs device capability, and updated suggestions regarding the prescription, billing, and coding of pediatric apnea monitors for pediatric practice management. (CHEST 2008; 134:425 429) Key words: apnea monitor; apparent life-threatening event; billing; cardiorespiratory monitor; coding; infant monitor; sudden infant death syndrome Abbreviations: AAP American Academy of Pediatrics; ICD-9 International Classification of Diseases, Ninth Revision; SIDS sudden infant death syndrome What is a Pediatric Home Apnea Monitor? Apnea monitors are devices designed to detect abnormalities in cardiac or respiratory activity, specifically activity that is too fast, too slow, or absent. For clarity, pediatric home apnea monitors are not made for the diagnosis of sleep-disordered breathing in a child. The reasons for this will become apparent in the discussions below, but diagnostic sleep studies (polysomnograms, *From the Department of Pediatrics and the Children s Hospital Sleep Center, The Children s Hospital and University of Colorado, Denver, Health Sciences Center, Aurora, CO. This article was supported by grant K23RR024257. The author has no actual or potential conflicts of interest, real or perceived, to disclose. Manuscript received February 27, 2008; revision accepted April 10, 2008. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Ann C. Halbower, MD, Director, Pediatric Sleep Research, The Children s Hospital and University of Colorado, Denver, School of Medicine, 13123 E Sixteenth Ave, B-395, Aurora, CO 80045; e-mail: halbower.ann@tchden.org DOI: 10.1378/chest.08-0538 or limited-channel pneumograms) are coded separately, and used for diagnosis as opposed to ongoing monitoring of cardiorespiratory events for parental intervention. Home use of the apnea monitor was initiated 30 years ago during the time of research centered on the apnea hypothesis, in which prolonged apnea was hypothesized to be a cause of sudden infant death syndrome (SIDS). 1,2 Home apnea monitors were designed with the intent to protect infants from death by identifying episodes of central apnea or bradycardia, signaling the parent to intervene before the event became terminal. Later, devices were developed that could record the data for downloading so that events could be examined by a health-care provider. 3 Regrettably, there were no randomized or controlled studies of device efficacy for a life-saving role before monitors were made available to the public. Although there have been several studies 4 6 on monitors regarding issues such as compliance, access to devices, quality of life, and duration of monitoring, few studies have examined whether cardiorespiratory apnea monitor devices were associated with a www.chestjournal.org CHEST / 134 / 2/ AUGUST, 2008 425

difference in outcome compared to the unmonitored infant, especially when the outcome measured was death. The high death rate of infants first using the home monitor 1 should have alerted researchers to question whether the use of apnea monitors, alternative devices such as pulse oximeters, or any device could result in improved outcomes for infants at risk. In fact, one important study 7 on national prevalence of apnea monitor use revealed two disturbing findings: a racial discrepancy for access to monitors, and that low-birth-weight black infants using monitors still had an odds ratio for SIDS of 3.93 compared to unmonitored infants. These studies raised a red flag that standard apnea monitors may not be life-saving devices, and that other risk factors such as low birth weight or race, and perhaps other devices might be the focus for increased targeted-prevention efforts. Regardless of the paucity of evidence for efficacy, home monitor use spiraled internationally in the last 35 years, 8 but the incidence of SIDS did not decline until public education resulted in changes to modifiable SIDS risk factors in just the last 10 to 15 years. 9 11 The American Academy of Pediatrics (AAP) has published recommended indications for apnea monitors, 12 comprised of a long list of various disease states that have not undergone any more evidence-based study of device efficacy compared to recommendations set forth in 1987. 13 The fear of sudden unexpected death in infants is understandably an emotional subject, leading to a desire by parents and providers to protect infants at risk, with the unfortunate result of a possible false sense of security offered by a device designed to detect limited types of events. Apnea monitors are now frequently prescribed for home use in infants and in children for various reasons, 14 reflecting a lack of understanding about what the devices are designed to do and what the device limitations are. What Does a Home Apnea Monitor Do? There are now several types of apnea monitors on the market for home use, and knowledge of device function will help guide the health-care provider in the choice of device, or in the choice to not use a device at all. The AAP has published clinical scenarios that might warrant the use of a home apnea monitor in pediatrics 12 : There are other groups of infants for whom use of a home cardiorespiratory monitor may be warranted, not because of an increased risk of SIDS, but because of other factors that increase the risk of sudden death. For example, home cardiorespiratory monitoring may be justified to allow rapid recognition of apnea, airway obstruction, respiratory failure, interruption of supplemental oxygen supply, or failure of mechanical respiratory support. Infants for whom these indications may apply include: 1) infants who have experienced an apparent life-threatening event; 2) infants with tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise; 3) infants with neurologic or metabolic disorders affecting respiratory control; and 4) infants with chronic lung disease (bronchopulmonary dysplasia), especially those requiring supplemental oxygen, continuous positive airway pressure, or mechanical ventilation. In these instances, home cardiorespiratory monitoring may allow the caregiver to respond more quickly and perhaps to decrease the duration of accompanying hypoxemia. This statement generalizes the function of apnea monitors, and may lead to the common misperception that a standard apnea monitor can detect hypoxemia or obstructive apnea. The standard home apnea monitor provided by major homecare companies is designed only to detect breathing effort and heart rate with a two-channel signal. A lack of breathing effort is a central apnea and is the type of apnea that these monitors are designed to detect. Central apnea is common in preterm infants. The signal displayed is an impedance signal from a chest strap or electrodes indicating chest movement (a pause in that movement for a set number of seconds sounds an alarm and starts the recording). Bradycardia, a slow heart rate, is also common in preterm infants and is detected by standard home monitors, as is fast heart rate (tachycardia). The heart rate is often displayed as a gross QRS ECG signal such as that seen on a rhythm strip. The events recorded by an apnea monitor can typically be downloaded to a computer (with the appropriate software) so that each event (including a recording several seconds before and after the alarm) can be viewed. The monitor will also record hours of use per day and per month. Standard home-use apnea monitors do not detect obstructive apnea (indicated by ongoing struggling or labored breathing that is sensed as ongoing respiratory activity), nor does the standard apnea monitor detect hypoxemia. The Collaborative Home Infant Monitoring and Evaluation study 15 demonstrated that infants with monitored respiratory events were frequently (70%) having obstructive events that are not detected by standard monitors. In fact, because of the prolonged time it takes for bradycardia to develop in a child, or agonal breathing from an obstructive event that will precipitate an alarm on the standard monitor, hypoxemia and reflex bradycardia are likely to be profound, and the event might be difficult to reverse. 16,17 This may be one reason why apnea monitors did not reduce the incidence of SIDS in the 30 years they were used by the public. Pulse oximeters are available on special apnea monitors, but these monitors are more costly, use more memory, are larger, and there is a state-to-state 426 Topics in Practice Management

variability regarding reimbursement for the added oxygen saturation signal. A special order for the addition of a pulse oximeter to an apnea monitor, or for a device that includes oxygen saturation monitoring is required because oxygen saturation monitoring is not available on the default cardiorespiratory monitor. As with cardiorespiratory monitors, devices with oxygen saturation monitoring have not been tested in controlled trials of device efficacy regarding outcome compared to standard apnea monitors. Thus, recommendations about home monitoring for infants or children with tracheostomy tubes (at risk for decannulation), bronchopulmonary dysplasia, children on oxygen therapy, or children on ventilators, as well as the discharge of premature infants requires careful thought by the prescribing physician. Many of these disorders put children at risk for hypoxemia or obstructive apnea, and not central apnea. Hypoxemia was found to be a preliminary event in a majority of infants having apparent lifethreatening events 18 ; and although further study is indicated, oxygen saturation monitoring may be important for early identification of events. 19 When Should Apnea Monitors Be Prescribed? Home monitors are used to notify first the parent and later the health-care provider that central apnea and heart rate extremes are occurring. The device is designed to alert the parent that intervention (stimulation, mouth-to-mouth resuscitation, cardiac compressions) is required. The event is recorded so that the interpreting health-care provider can determine a course of action. That course of action is dependent on the reason the device was prescribed, the expected rate of events, and whether or not the child needs a new diagnostic evaluation. This statement presupposes that the prescribing provider is the same (or in communication with the) person viewing and interpreting the downloaded events. It is important that the prescribing provider have the following: (1) a reason for suggesting a monitor that records central apneas and heart rate extremes; (2) an estimation of the duration of need; (3) a plan for what intervention will be suggested should events increase beyond the expected duration of time; (4) communication with the person interpreting the data if not done by the provider; (5) and a termination date on the monitor. The most common reason for ordering a home apnea monitor is to monitor known apnea of prematurity in newly discharged premature infants. Infants are at increased risk of cardiorespiratory events until 43 weeks post-gestational age. 15 There is evidence that the earlier the preterm delivery, the longer the expected events after birth. 20 Logic would dictate that the medical diagnoses used to justify an apnea monitor would include infants or children at risk for central apnea or extremes of heart rate for which the monitor is designed to alarm. These indications include central hypoventilation, central apnea associated with brain injury or CNS dysfunction, apnea of prematurity, and infants being weaned from caffeine who are at risk for increasing apnea. The use of an alarming pulse oximeter in combination with the monitor or used alone may be indicated when infants are at risk for obstructive breathing efforts or hypoxemia. 21 Recent pulse oximeters have been improved in regards to movement artifact, 22 although no device is without false alarms. Finally, parents should be instructed on the expected response to an alarm given the diagnosis. A parent sent home with a pulse oximeter but without oxygen or devices for bag-mask ventilation is not able to make appropriate interventions when the monitor alarms. Parents should be counseled in proper cardiopulmonary resuscitation techniques and stimulation efforts if the monitor should alarm. Parents should be aware of the stress caused by frequent false alarms. 23 They should observe the infant during an alarm, with lights on and shirt lifted, to determine if the alarm is false. Parents should also be counseled that the monitor is not tested or designed to protect infants in unsafe sleep conditions (sleeping prone, or sleeping with smoking/drinking parents, sleeping with many family members in the same bed, exposed to cigarette smoke, or if infants are heavily bundled or overheated). Studies 7,9 show that infants can die regardless of prescribed monitor use, and therefore a safe sleep environment is especially critical in highrisk infants. Infants should be in a safe crib with a mattress designed for infant sleep, and they should be sleeping in the parent s room. 10 Infants should be in a smoke-free environment, with little wrapping, and the head free of covers. 9 Former preterm infants have a much higher risk of death, especially when exposed to the above risk factors compared to term infants. 24 African-American and Native-American infants have two to three times the risk of death compared to the national average. 25,26 Selecting infants at high risk for sudden death to use an apnea monitor should be a signal to health-care providers to spend valuable counsel time with parents to decrease environmental dangers that increase the risk of death for all infants, especially those 6 months of age. If the monitor has not detected events in several weeks and the infant is beyond 43 weeks postgestational age (unless he or she was very premature), 20 the monitor may be discontinued; the infant then carries the same risk as the general population. 15 Monitors have been left on infants and chilwww.chestjournal.org CHEST / 134 / 2/ AUGUST, 2008 427

dren for months or years at great insurance expense when prescribed at hospital discharge without a responsible follow-up plan, and the only beneficiary is the durable medical equipment company. If the monitor continues to record events, or alarms become unexpectedly more common, the infant deserves a medical evaluation to determine other causes for increasing cardiorespiratory events. Occasionally, monitors may alarm due to abnormal cardiac rhythms, central apneas, or bradycardia related to other disorders such as gastroesophageal reflux or seizure disorders. These disorders, or reported cyanosis, unusual movements, labored breathing, or noisy breathing deserve further diagnostic evaluations such as a polysomnogram, ph probe, gastroesophageal imaging, EEG, or swallow study, followed by appropriate treatment. The apnea monitor should therefore not be considered a diagnostic tool, or a treatment for a cardiorespiratory disorder. Billing and Coding Information A series of new current procedural terminology codes have been created to allow for coding and billing for pediatric home apnea monitoring in the United States (codes 94774 94777). Medical necessity for the use of the monitor must be documented in the medical records and frequently provided to the insurance company. Necessity of service is established with documentation of a review of the problem and a plan of care along with the rationale for the plan. Medical necessity criteria vary by thirdparty insurance carriers but include the diagnosis of apnea of prematurity. Also included are infants with an apparent life-threatening event (an episode characterized by some combination of apnea, color change, marked change in muscle tone such as marked limpness, choking, or gagging 27 ). Other indications for apnea monitors include bradycardia or disorders affecting respiratory control, or disorders mentioned in the guidelines developed by the AAP. 12 Again, the majority of these indications are not evidence based, and it is not clear whether standard monitors add any benefit to proper parental education about risk factor avoidance in infants with many of these diagnoses other than apnea of prematurity. Insurers use the International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code to demonstrate medical necessity for services. When ordering an apnea monitor, for example, in addition to the clinical documentation in the medical record, the most specific diagnosis(s) codes must be provided to the insurer. For example, the ICD-9 diagnosis code series 770.8x is used to identify other respiratory problems after birth. This series of codes includes a variety of clinical conditions. ICD-9 code 770.8 is considered a base code and as such is incomplete. In order to accurately describe the reason the apnea monitor was ordered, it is critical to select and include the appropriate fourth and fifth digits of the ICD-9 code; not doing so may result in denial of the requested service. For example, if the reason for ordering the apnea monitor is newborn apnea, the appropriate diagnosis code would be 770.81. Most insurers have medical policies available on their Internet sites. Providers may look to these policies for specific details regarding covered diagnosis codes. Code 94774 is used for reimbursement for a full month of pediatric home apnea monitoring event recordings, including respiratory rate, pattern and heart rate, monitor attachment, download of data, physician review and interpretation, and preparation of a report. This code should not be used during the same reporting period as 94775-7. There are two codes used when home-care companies share the responsibility for monitor downloads such as monitor hook-up, initiation of recording, and disconnection (94775). There is a separate code for monitoring, download, and analyses by computer only (94776) used by home-care companies, as well as a code for physician review, interpretation, and preparation of report only (94777). Oxygen saturation (although it is not standard) is not coded separately when it is used along with an apnea monitor download. Again, it is important to note that diagnostic sleep studies (home or laboratory polysomnograms, or limited channel sleep studies) are not equivalent to apnea monitor downloads, and these are coded separately. Insurance carriers must be contacted regarding reimbursement because some companies will not authorize both apnea monitor downloads and pneumogram studies at the same time. Although individual insurance companies will provide reimbursement information, other helpful Web sites include those from major manufacturing companies that supply apnea monitors (http:// reimbursement.respironics.com/). These Web sites (and the government relations directors for the company) often carry up to date billing, coding, and reimbursement information for the products they sell by state. It is best to be mindful of the stateto-state differences in reimbursement, as well as products that vary in availability depending on the country. For reimbursement problems, health-care providers should contact their regional Centers for Medicare and Medicaid Services office at http:// www.cms.hhs.gov/ under About CMS, Agency Information. More coding information is available through the AAP Web site at http://www.aap.org/, where Coding for Pediatrics 2007, Twelfth Edition can be pur- 428 Topics in Practice Management

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