Health Information Management

Unanticipated January NCCI code update could have significant impact

APCs Insider, February 28, 2014

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The January 2014 update to the NCCI Coding Policy Manual contains a change that could significantly impact reimbursement, although the change was not noted in the CPT® code description or mentioned in the 2014 OPPS Final Rule.
The update involves code 94640 (pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing device]).
"Code 94640 is a very frequent service during an observation stay," says Valerie A. Rinkle, MPA, associate director with Navigant Consulting in Seattle. "Patients with shortness of breath or COPD are often given four or five treatments per day, which have always been billed per individual treatment and paid under OPPS per individual treatment."
However, in Chapter XI, Section J, Number 8, the January 2014 NCCI update states:
CPT code 94640 should only be reported once during a single patient encounter regardless of the number of separate inhalation treatments that are administered. If CPT code 94640 is used for treatment of acute airway obstruction, spirometry measurements before and/or after the treatment(s) should not be reported separately. It is a misuse of CPT code 94060 [bronchodilation responsiveness, spirometry, pre- and post-bronchodilator administration] to report it in addition to CPT code 94640. The inhaled medication may be reported separately.
The 2014 CPT Manual description for the code remains unchanged, including a parenthetical about using modifier -76 (repeat procedure or service by same physician) when reporting more than one inhalation treatment performed on the same date. The NCCI update does not explicitly state to no longer use the modifier, but it is implied.
The procedure has a per-treatment 2014 OPPS rate of $78.14, so the change could significantly affect reimbursement for facilities. The OPPS rule did not address this code and it does not appear that CMS adjusted the payment rate to reflect this NCCI change.
Providers should confirm this change with their Medicare contractors and commercial payers to ensure they're following the latest guidelines.  
One implementation strategy is to continue to charge each individual treatment and use a bridge routine with your claim scrubber software to reduce the units to one. Then, sum the charges for fee-for-service Medicare and other payers who are applying this new edit. This ensures the correct charges are reported on each claim for the level of effort expended.


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