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Let’s Be Clear

Written by: Vester Gravley on Monday, December 19, 2016 Posted in: CPT Code 94640, CPT Coding, episode of care, NCCI

lungsSometimes “clear” is only as clear as mud. This can be especially true when the correct answer is given to the wrong question. The recent clarification made by the National Correct Coding Initiative regarding what constitutes an “episode of care” may only deepen the confusion.

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The CCI update for CPT Code 94640 changes the language from “patient encounter” to “episode of care” and now states: “CPT code 94640 should only be reported once during an episode of care regardless of the number of separate inhalation treatments that are administered.” “Episode of care” is then spelled out: “An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.”

Now, this is the correct answer to the question, “What constitutes an episode of care for an outpatient hospital visit?” However, if this answer is misapplied to the question, “What constitutes an episode of care for an inpatient hospital visit?”, it will serve only to agitate the already deeply muddied waters! This would then mean only ONE nebulized treatment could be billed for the patient’s entire hospital stay. Some Medicare contractors have already been interpreting “patient encounter” in this manner. I suspect many will take the updated language as vindication of their position. However, a more complete reading of the new language clearly supports only the outpatient application of this rule: “If a patient receives inhalation treatment during an episode of care and returns to the facility for a second episode of care that also includes inhalation treatment on the same date of service, the inhalation treatment during the second episode of care may be reported with modifier 76 appended to CPT code 94640.”

Now that provides clarity! Inpatients do not “return to the facility for a second episode of care.” That would be a readmission. Perhaps the answer being given was always to the correct question, which was never about inpatients.  Either way, the new rule goes into effect in January 2017.  Happy New Year!