Reimbursement for Downloading Data Card Datahttp://reimbursement.respironics.com/downloads/Encore_Pro_Software_062106.pdf?file=1025847_EncoreProSmartCardSlpLink_HelpfulHints.pdf
HELPFUL HINTS FOR FILING
Encore® Pro SmartCard®
The following provides an overview of coding, coverage and payment for services associated with the download and interpretation of the Encore Pro SmartCard when performed in a physician’s office. Coding information and national average Medicare fee schedule amounts are listed on the back. The fee schedules do not take into consideration geographic practice cost indices.
Although accurate coding is essential to ensure prompt claims processing and reimbursement, inclusion of a specific code and fee schedule amount does not guarantee payment. It is critical to be aware of each payer’s coverage guidelines. For information regarding specific reimbursement guidelines, including coding, coverage and payment, please consult your local payer, the Federal Register or the Physicians’ Current Procedural Terminology (CPT)1. The Respironics Reimbursement Support Line can also further address your complex reimbursement issues.
When selecting a CPT code, health care providers should choose the one that most accurately identifies the procedure or service performed. In addition to diagnostic or therapeutic procedures, the physician may also report other medically necessary procedures that are performed. All procedures and services should be accurately documented in the patient’s medical record.
General Coding Guidelines
There are several factors to consider when selecting a CPT code to report the download and interpretation of data from the Encore Pro SmartCard. The first factor is whether the physician has face-to-face contact with the patient during the office visit that involves the download and interpretation of data. Providers should also consider the payer that is being billed. Payers may
have additional guidelines or specific coding recommendations for these types of services. Providers should contact the payer directly to confirm the most appropriate coding for these services.
Physician has direct (face-to-face) patient contact
If the physician has direct (face-to-face) contact with the patient, several coding options exist for the download and interpretation of data from the Encore Pro SmartCard.
• If the visit is in conjunction with a follow-up office visit for management of a patient’s PAP therapy, it may be appropriate to report the following code:
94660 Continuous positive airway pressure ventilation (CPAP), initiation and management
• Another option for reporting follow-up visits for management of PAP therapy is with the appropriate Evaluation and Management (E/M) CPT code. These codes vary according to the patient status (new or established), and the complexity of the presenting problem as documented in the patient record. When selecting an E/M code, there are several components
that physicians and their billing staff should consider and document:
Sample E/M codes used to report physician office or outpatient services for established patients include:
99212 Evaluation and management, established patient, presenting problems are self-limited or minor
99213 Evaluation and management, established patient, presenting problems are of low to moderate severity
99214 Evaluation and management, established patient, presenting problems are of moderate to high severity
Providers may not bill an E/M code in addition to CPT code 94660 for the same patient service. An E/M code may be reported in addition to CPT code 94660 only if there is a “significant, separately identifiable service” above and beyond management of the PAP therapy.
1 Current Procedural Terminology (CPT), Fourth Edition, 2003. American Medical Association, 2002. All rights reserved.
• Patient history
• Type of examination
• Level of medical decision-making
• Counseling provided
• Coordination of care
• Nature of presenting problem
• Time spent in direct contact with the patient or family
• Additionally, there are several CPT codes that may be used by providers to report special services, such as the download and interpretation of Encore Pro SmartCard data. For example:
99090 Analysis of clinical data stored in computers (e.g., ECGs, blood pressure, hematologic data)
99091 Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, requiring a minimum of 30 minutes of time
Code 99090 may be used to report the interpretation of Encore Pro SmartCard data, and
99091 may be appropriate to report both the download and the interpretation of the data. Providers should not report both of these codes for one service encounter.
Physician does not have direct (face-to-face) patient contact
In the absence of a face-to-face encounter between the physician and the patient, coding options for reporting the download and interpretation of Encore Pro SmartCard data will vary.
• One option is to report the download and interpretation with a miscellaneous CPT code, such as:
99499 Unlisted evaluation and management service
The American Medical Association (AMA)2 has confirmed that this CPT code may be used by providers to report interpretation of Encore Pro SmartCard data in the absence of an actual patient office visit/encounter. As this is a miscellaneous code, providers should attach supporting documentation to the claim, such as an explanation of services provided and the medical necessity for those services. The payment level for this code will be determined on a case-by-case basis upon individual payer review.
• Another option is to report the download and interpretation of Encore Pro SmartCard data with 99090 or 99091. Again, code 99090 would be used to report the interpretation of the data, and 99091 may be appropriate to report both the download and the interpretation of the data. Providers should not report both of these codes for one service.
Coverage and Payment Guidelines
Under Medicare, codes 99090 and 99091 have a “bundled” status. This means Medicare payment for these codes is bundled into reimbursement for other basic services rendered. Even though these codes are not separately reimbursable under Medicare, providers may report these codes when appropriate to represent the additional time and resources spent providing these services.
E/M codes and CPT code 94660 are eligible for Medicare coverage and payment. If an E/M code is billed in conjunction with CPT code 94660, payment will be bundled, unless a “significant and separately identifiable service” is provided. Payment is based on the Medicare Physician Fee Schedule. The following table indicates some sample coding options and corresponding national average
Medicare fee schedule amounts:
2004 National CPT Code Description Average Medicare Code Fee Schedule Amount*
94660 CPAP initiation and management $54.51
99212 Evaluation and management, established patient, presenting problems are self-limited or minor $37.71
99213 Evaluation and management, established patient, presenting problems are of low to moderate severity $52.65
99214 Evaluation and management, established patient, presenting problems are of moderate to high severity $82.14
99090 Analysis of clinical data stored in computers (e.g., ECGs, blood pressure, hematologic data) Bundled
99091 Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the Bundled physician or other qualified health care professional, requiring a minimum of 30 minutes of time
99499 Unlisted evaluation and management service Manually priced
2 Based on guidance provided by AMA’s CPT Information Services representatives.
* 69 Fed. Reg. 1083–1267 (2004) (to be codified at 42 CFR 405 and 414)
Private Payers and Medicaid
Private payers and Medicaid programs reimburse providers for professional services in a variety of ways, including fee schedules and a percentage of the usual and customary charges. CPT-4 codes 99090 and 99091 may be considered bundled by some private payer plans, while other plans may provide separate reimbursement. The provider should contact the specific plan to determine actual payment rates.
Note: Inclusion or exclusion of a code for a specific product or supply does not imply any health insurance coverage or reimbursement policy.
All referenced information and codes were taken from HCPCS. Please refer to DMEPOS Supplier Manual for complete explanations.
FOR MORE INFORMATION FROM RESPIRONICS CONCERNING Reimbursement Contact Website/Phone
Information & Fee Schedules Respironics Website http://www.respironics.com
Educational Materials & Questions Customer Service 1-800-345-6443; listen to the instructions (coding, coverage & payment) and follow prompts to select the Insurance Reimbursement Information option
Government Relations Consulting Services 1-724-387-4475
1020314 SB 3/24/04
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