ED Coding and Reimbursement Alert

Here's why your physician will rarely provide 94002, 94003 solely.

If your physician provides initial-day ventilation management services in the course of treating a critically ill or injured patient, be sure you choose a critical care code instead of a ventilation management code or you're leaving about $127 on the table.

The reason: Ventilation management, when performed, is bundled into the critical care code (and most other E/M codes); these codes pay out at a higher rate than the ventilation management codes, explains Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

Also, An E/M code is more often a better representation of your physician's services than 94002 or 94003. Further, ventilation management codes are bundled into most E/M codes, including critical care, reminds

The benefit: When your ED physician provides ventilation management, it is usually for a patient requiring high-level ED E/M service, subsequent hospital care, or even critical care. Check out this expert advice on when, and when not to, rely on ventilation management codes.

No E/M Evidence? Use 94002-94003

The 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing: hospital inpatient/ observation, initial day) and 94003 (... hospital inpatient/observation, each subsequent day) CPT codes are used mostly by pulmonologists, though it is possible the ED physician services in certain instances, says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

Example: A snowstorm has caused short staffing at a hospital, and the ED physician is called by the critical care unit (CCU); the pulmonologist cannot get to the facility, so the CCU asks the ED physician to see a patient with congestive heart failure (CHF) who suffered acute respiratory failure; the patient had been placed on a ventilator two hours earlier. The ED physician reviews the latest blood gas and adjusts the ventilator settings appropriately and documents data necessary to provide the initial day of ventilator care.

On the claim, you would report the following:

• 94002 for the physician's ventilation management service
• 518.81 (Other diseases of lung; acute respiratory failure) appended to 94002 to represent the patient's respiratory failure
• 428.0 (Heart failure; congestive heart failure, unspecified) appended to
• 94002 to represent the patient's CHF.

Explanation: Since the patient was already intubated and placed on the ventilator and no additional E/M service was performed, the physician would only report his ventilation management services.

The average payout for 92003 is $90 (2.67 transitioned facility relative value units [RVUs] multiplied by the 2011 Medicare conversion factor of 33.9764) , while 92004 pays an average of $65 (2.85 RVUs times 33.9764).

Consider E/M First, If Physician Goes Beyond 94002, 94003

If the notes indicate that the ED physician provided ventilation management in the course of a greater E/M service, you'll want to be sure to bundle all of the encounter work and choose the proper E/M code, says Jill M. Young, CPC, CEDC, CIMC, with Young Medical Consulting LLC in East Lansing, Mich.

Reason: With few exceptions, the physician will provide a high-level ED E/ M service (99284, 99285, 99291), which is reimbursed at a more substantial rate than the ventilation management codes.

Example: At 4 a.m., the ED physician is called by the critical care unit (CCU), which asks the ED physician to see a patient with congestive heart failure (CHF) who suffered acute respiratory failure; the patient had been placed on a ventilator two hours earlier. The ED physician performs a history and physical exam; and reviews lab work, blood gases, ongoing laboratory studies and consultants' notes and recommendations for ongoing treatment. The ED physician documents ventilator settings and, based on the recent blood gases, makes an adjustment to the ventilator settings, along with the data necessary to provide the initial day of ventilator care; notes indicate 12 minutes of ventilator management.

In order to further stabilize this critically ill patient, the physician spends another 48 minutes providing critical care services including adjusting active medications and changing the patient's antibiotics.

Since the physician provided critical care for the patient, you would add up total session minutes (48 + 12 = 60) and report 99291 (Critical care, evaluation and management of the critically ill or critally injured patient; first 30-74 minutes) for the physician's services.

Check this out: The Medicare payout for 99291 is around $ 217 (6.39 RVUs times 33.9764).

Even if the physician was not providing critical care in the above example, he would likely perform a level-four or five ED E/M service. The payout for 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity ...) is about $ 115 (3.4 transitioned facility RVUs times 33.9764).

The average payout for 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) is $169 (4.98 times 33.9764).