Understanding New Patient Education Codes

Vol. 15 •Issue 3 • Page 11
Coding Connection Q & A

Understanding New Patient Education Codes

Q: What’s necessary for patient education to use CPT code 98961? How much time do I spend, and what material must I cover? We’re interested in having appointments for recently diagnosed asthma patients. Do you know what the reimbursement will be? When does this take effect?

A: The code isn’t listed as being assigned a relative value or a fee in the 2006 Medicare fee schedule, which means it won’t reimburse for this code. Whether other payers will or not is yet to be seen. I wish that I could give you more details, but the codes are new, and no one has experience with them yet. It’s strictly up to the payers whether or not they will pay for this type of patient education.

The CPT description for 98960-98962 is, “Education and training for patient self-management by a qualified non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes.” 98960 is for an individual patient; 98961 is for two to four patients (group); and 98962 is for five to eight patients (group).

As with other education codes, the “standardized curriculum” caveat is essential here. You must use a program approved or endorsed by a professional organization in our specialty such as the American College of Chest Physicians or American Academy of Sleep Medicine.

There’s also the caveat, which we presume will be enforced, regarding a “qualified non-physician health care professional,” meaning an individual with some form of state licensure such as an NP, PA, RN, LPN/LVN, RRT, etc.

Unattended Sleep Studies Not Covered

Q: What’s the code for unattended all night cardiorespiratory monitoring (sleep apnea screening with multiple recording parameters)? What’s the typical reimbursement from Medicare?

A: The code for an unattended sleep study is 95806. Medicare did an extensive review of the issue of payment for unattended sleep studies and reported in September 2004 that there was insufficient evidence to justify Medicare reimbursement for this procedure.

Therefore, it isn’t a covered service under Medicare and would be a “patient responsibility” service — with appropriate signing of an Advanced Beneficiary Notice (ABN). The code would be appended with modifier GA to indicate that the signed ABN form is on file. Medicare would then notify the patient that he owed the provider for this service on denial of the procedure as a noncovered service.

No Specific Code for Heliox

Q: What CPT code should be used for heliox therapy, and how should it be billed: daily or by the hours of use?

A: No CPT code or Medicare/Medicaid coverage exists specifically for heliox therapy — the use of an oxygen/helium mixture to deliver inhaled medication via nebulizer. (Heliox improves lung deposition of inhaled particles when compared with air or oxygen inhalation.)

The most appropriate code available is 94640, which is the standard nebulizer treatment code. This code is per treatment, so be sure to report the number of treatments as “units” when billing.

You also might try using 94799 and send a report. This is the unlisted pulmonary service code, and it leaves the payment to payer discretion.

Progress Notes Key When Billing for CPAP Problems

Q: As part of a sleep clinic that operates at our sleep lab, we see patients with problems using continuous positive airway pressure and bilevel positive airway pressure. As this patient population grows, we’re wondering if there’s a way to bill for our time.

A: If this service is performed under the supervision of a physician (not requiring his or her personal presence), the appropriate code for management of problems with a home CPAP device would be 94660. It’s our experience that many payers want to see progress notes when billing for this service, and that it’s generally paid no more than semiannually.

What to Do With High-flow Nasal Cannula

Q: How would you code for use of high-flow nasal cannula?

A: There’s no way to specify high-flow nasal cannula vs. low-flow nasal cannula in supply billing in a facility. Medical offices can’t charge for supplies.

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

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