Reimbursing Complementary Medicine

Vol. 15 •Issue 7 • Page 12
Coding Connection Q & A

Reimbursing Complementary Medicine

Q: I have an office that provides services in the area of complementary medicine, including a lot of patient education. As an RRT, RCP, can I get insurance reimbursement for my services?

A: The vast majority of payers don’t recognize RRTs’ and RCPs’ services to be reimbursable separately. The only “mid-level” or “limited license providers” recognized by Medicare for reimbursement purposes are nurse practitioners, physician assistants, clinical nurse specialists, nurse midwives, podiatrists, psychologists, and chiropractors.

Most third-party payers (including PPOs, HMOs, workers’ compensation, etc.) follow either Medicare’s policy or have their own that’s more limited, not recognizing NPs, PAs, CNSs, or nurse midwives.

Bill for Interpretation of Methacholine Challenge

Q: Since code 95070 doesn’t split into technical and professional components, is it possible to bill for the interpretation only of a methacholine challenge test?

A: Just because Medicare’s fee schedule doesn’t list the 95070 code distinctly with a global fee (no modifier required), a technical fee (-TC) and a professional fee (-26) doesn’t preclude you from billing the code with appropriate modifiers.

Be prepared to appeal, however, should your claim be denied for your interpretation. I’d also suggest checking with the office/hospital that did the test to be certain that it append its claim with modifier -TC.

Is CPT 94762 Reimbursable?

Q: Our New York facility is investigating performing nocturnal oximetry on an outpatient basis. We have been told that CPT 94762 has a status indicator of “N,” meaning it’s considered an incidental service and not reimbursable. Is this true, and if so, is there another way to charge for this?

A: The “N” indicates that it’s not payable with a physician visit. Upstate New York Medicare fee schedule lists the approved payment at $18.90. No form of visit code can be charged on the same date, or this code will be bundled and denied.

What to Charge for Telemedicine EEG Reports

Q: We provide telemedicine EEG reports, and I was told from the company that we could bill the physician charge since we’re paying them per test. At present time, we’re only using CPT code 95816. Is there something else we could be charging?

A: The telemedicine industry has exploded since 2003. Unfortunately, payment by Medicare and third-party payers hasn’t kept pace. There are two ways to establish reimbursement criteria with the company that you’re providing this service for.

1. Simply provide the interpretation service to the company and expect it to pay you a fair-market-value fee for that service. This is by far the most simple and efficient way.

2. Get the patient demographics, including date of service, payer information, and other relevant information from the company, and do the billing for the test (in your case 95816-26), making sure that the company bills with a -TC modifier, and deal with the denials and payment delays that can occur because the payer hasn’t established a policy on paying for telemedicine services. Some payers will simply pay your interpretation fee (per their fee schedule), and some will balk. There’s no consistency at the current time.

Currently, no specific CPT/HCPCS codes exist for additional payment for telemedicine services.

Codes Bundled Into a Pulmonary Compliance Study

Q: What CPT codes are bundled into CPT 94750 — pulmonary compliance study? Am I safe saying it includes 94150, 94375, 94010, and 94060? I work at Evans Army Community Hospital, Fort Carson, Colo.

A: According to the April 2006 CCI, 94750 — pulmonary compliance study — isn’t officially bundled into any other pulmonary function test. Colorado Medicare and many other regional payers, however, won’t pay this code in conjunction with “body box” codes — 93720-93722. If the test is performed independently, it should be reimbursed.

Limits for Modifiers

Q: Is there a limit on using CPT modifiers?

A: Electronic billing limits the number of modifiers per CPT code to four. The new (August 2005) edition of the CMS 1500, which is available for use effective Oct. 1, 2006, (mandatory use is Feb. 1, 2007), also has space for up to four modifiers. The current (December 1990) version only has room for two modifiers.

CPT Code to Review, Interpret PFT Test

Q: We currently perform pulmonary function testing in our office with equipment that our physicians own. We have just started accepting outside referrals to perform the test which the referring physicians bill for. We have been billing CPT 94016 for only the review and interpretation of the test, but Medicare denies the claims as not medically necessary.

Is there another CPT code that we can use for the review and interpretation of the PFT test? This testing is under the review of the pulmonologist and can be time consuming for him; is there some way to reimburse him for his time?

A: The CPT code that you’re using is for physician review and interpretation of a “patient-initiated spirometric recording, per 30-day period of time” (transtelephonic spirometry), not for PFT services.

Transtelephonic spirometry requires the patient to perform the spirometry based on time intervals or criteria predetermined by the physician. The results are stored in a small computer that’s part of the spirometer. The data are downloaded via modem from the spirometer’s computer to another computer. The data are then trended and analyzed to identify problems. This service includes all measurements, transmissions, and interpretations over a 30-day period.

If you’re performing the entire PFT service, including administering the test and interpretation/report, the proper coding would be:

  • 94060: bronchodilation response
  • 94240: FRC (helium/nitrogen washout), if performed
  • 94260: thoracic gas volume, if performed
  • 94720: DLCO, if performed
  • 93720: body box, if performed.

    If you want to charge only for physician interpretation and let the outside doctors bill for the technical component and pay you a fee for use of your equipment/staff, the codes are appended with modifier -26 to indicate the physician component.

    The other practice would bill with a -TC modifier and indicate that it has purchased the technical component on the claim in field No. 20 on the CMS 1500 along with your UPIN/NPI number in field No. 19 to identify who performed the test. The other office can’t charge Medicare more than it pays you for its portion of the service.

    See or and search on “purchased diagnostic services” for more complete information. Neither your practice nor the practice billing for the technical component may bill globally for this service.

    As a certified health care compliance consultant, I’m concerned that you’re letting an outside practice bill for the technical component on equipment that your practice owns.

    If this practice is making a profit on its payment for this service above what you charge it for use of your equipment — which might be frowned on under Medicare regulation — there could be Stark or other federal law issues under the “anti-kickback” statutes that apply to all insurance payments regardless of type of payer, not just Medicare, Medicaid, or Tricare.

    Please check with a qualified health care attorney (not a general practice attorney) to clarify the issue.

    Ray Cathey, PA-C, MHA, FAHC, CHCC, is the president/owner of Medical Management Dimensions in Stockton, Calif.