HealthNow New York Inc, doing business as Blue Shield of Western New York, updated its fee schedule for upstate New York to include reimbursement rates for home testing.
Those rates are:
Code PAR Fee Non PAR Fee Limiting Charge
G0398 $248.39 $235.97 $271.37
G0399 $191.09 $181.54 $208.77
G0400 $171.99 $163.39 $187.90
Reimbursement for type II devices was below industry expectations and type IV reimbursement was higher than expected. “The payment for G0399 type III testing device is not a surprise and almost identical to what was previously posted for CPT 95806,” says Landon Pendleton, director of product development, Instant Diagnostic Systems. “Some weight was given to the additional overhead involved in type II testing. The reimbursement rate for type IV devices is a bit of a surprise, however.”
Despite the rates, the DME MACs’ parameter definitions have made interpretation of type IV reimbursement challenging. “The DME MACs have clarified their expectations of the three channels for a type IV device … but a device that records effort, flow, and pulse oximetry would inherently meet the criteria for a type III device (two respiratory movement/airflow, ECG/heart rate, and oxygen saturation),” says Christian Kiely, marketing manager, Fisher & Paykel Healthcare Inc.
Pendleton echoes Kiely’s comments: “We are unaware of any type IV device on the market that would meet the definition set forth by the DME MAC LCDs. Further, it is doubtful that a manufacturer will ever release a device with this channel-set and classify it as a type IV device.”
Another point, says Pendleton, “Where does the Itamar WatchPAT fall in the reimbursement rates? Is it to be billed as a type IV device? Will the carrier’s policies provide coverage for tests taken with this device? One draft policy from Pinnacle, which covers Arkansas and Louisiana, has already stated they will cover only devices with ‘standard biosensors,’ which definitely seems to exclude the PAT signal.”
Unanswered questions remain as the industry waits for clarification and fee schedules from other regions. The rates released by HealthNow New York Inc are not necessarily an indication of what other regions will schedule as their reimbursement rates. “This is one carrier who has priced the codes but that speaks nothing of what other regions are going to pay,” Kiely says.
The 45 counties in New York that HealthNow New York Inc serves are Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chenango, Chemung, Clinton, Cortland, Erie, Essex, Franklin, Fulton, Genesee, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Ontario, Onondaga, Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, Steuben, St. Lawrence, Tioga, Tompkins, Warren, Washington, Wayne, Wyoming, and Yates.
The fee schedule changes can be read here.
On March 13, 2008, the following CMS G-codes went into effect:
• HCPCS code G0398 has been assigned to a “home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation.”
• Type III monitoring, designated by CMS as a “home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation,” has been assigned HCPCS code G0399.
• And for a type IV test, described by CMS as a “home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels,” code G0400 has been assigned.
In late July 2008, the DME MACs’ Local Coverage Determinations defined home testing devices as follows:
• Type II device – Monitors and records a minimum of seven (7) channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation; or,
• Type III device – Monitors and records a minimum of four (4) channels: 2 respiratory movement/airflow, ECG/heart rate and oxygen saturation; or,
• Type IV device – Monitors and records a minimum of three (3) channels that must include respiratory effort, airflow and oxygen saturation.
• Watch-PAT100 (Itamar Medical)