ED Coding and Reimbursement Alert

Question: What are we required to document when the physician administers ventilation management for a patient?

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Answer: If you perform vent management for patients in respiratory failure, pay attention to your physician's method of ventilation management, the date of care, and whether Medicare bundles E/M codes into the services. By understanding three essential points, you're sure to choose the right ventilation management code every time.

When your physician uses ventilation management to treat respiratory failure, you should choose from the following codes:

• 94002 --  Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day
• 94003 -- ... hospital inpatient/observation, each subsequent day

In terms of documentation, the physician should record the ventilator settings and adjustments. This includes the initial or current vent settings, any changes to those, and recommendations and/or orders relating to the vent setting changes.

Once you know how your doctor administered the ventilation, look at when he administered the treatment. Choose the correct code based on whether you're reporting the first day of ventilation or subsequent days. In some cases, the patient may be in the observation unit for more than one day, which would necessitate use of 94003.

You should report 94002 for the first day of the ventilation and 94003 for subsequent days. You'll look to the J96.xx series when your patient is diagnosed with respiratory failure, but you'll need to know a few details before you select the right code.

Sometimes physicians use the term "respiratory failure" as a general phrase when a patient has difficulty breathing. Your challenge is figuring out whether the physician intended for you to report a code for acute or chronic respiratory failure.

Best bet: The situation is even more confusing when the patient has chronic respiratory failure with an acute episode. It is likely that patients who are being hospitalized for their respiratory failure are experiencing some form of acuity. The key to using the right diagnosis code for respiratory failure is deciphering from your physician's documentation how quickly the patient normalizes his lung function between episodes of the respiratory disease.

Example:  Your physician treats a patient with end-stage emphysema who has consistently altered carbon dioxide and oxygen levels. The physician diagnoses the oxygen-dependent patient with chronic respiratory failure. The patient presents in the emergency department for an exacerbation of emphysema, which severely deteriorates the patient's already compromised condition, causing acute respiratory failure.

In this case, you would report J96.20 (Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia) for acute on chronic respiratory failure. The documentation on an arterial blood gas determination of an elevated PaCO2, elevated bicarbonate level, and a low pH help to substantiate the diagnosis of acute on chronic respiratory failure.

Keep in mind that 94002-94004 are listed among the codes bundled with critical care and as such should not be reported in addition to critical care services.