ED Coding and Reimbursement Alert

If you report ventilation therapy when your ED physician performed critical care, you could lose out on over $100 per claim. But breathe easy: If you focus on the encounter notes, you-ll know when to choose a ventilation assist code and when to opt for the E/M.

Patients who require ventilation assist and management present a unique coding challenge. The ED physician might provide the ventilation assist only, or he might provide ventilation services during the course of a high-paying E/M service, such as critical care.

According to CPT, all of the ventilation therapy codes mentioned in this article (94002, 94003, 94660, 94662) are bundled into E/M codes. Therefore, you cannot report ventilation therapy with an E/M service.

Impact: When your ED physician performs 94002, 94003, 94660 or 94662, you-ll need to decide whether to report the ventilation therapy or roll the work into the E/M level, says Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

Notes for these encounters will likely lead you to the proper code choice:

1. If the physician focuses on ventilation management services during the encounter and does not document key components warranting an E/M, report a ventilation management code only.

2. But if the notes describe an encounter in which the physician performs ventilation management during the course of a larger E/M, report the E/M code.

Benefit: Choosing to report the E/M instead of ventilation management, when allowable, may benefit the practice's bottom line. The E/M codes typically associated with ventilation management services require much more work and documentation -- and pay at a higher rate -- than the ventilation management codes.

"In most cases, if you did enough work to qualify for an E/M level, you would want to report the E/M," says Denae Merrill, CPC, coder for Covenant MSO in Saginaw, Mich.

Example: If you choose to report 94003 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day), but your physician provides services more in line with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), you will miss out on approximately $118 in work values.

The physician work relative value units (RVUs) reimbursement for 94003 is about $52 (1.37 RVUs), while 99291 pays about $170 (4.50 RVUs).

(Note: For more information on identifying critical care services, see "Prove Patient's Critical State Before Coding 99291" on page 19.)

Of course, you-ll also encounter situations in which the best coding option is a ventilation management code. If your physician treats a patient solely with ventilation assist and management, you-ll choose one of the following codes depending on the day of treatment, Contreras says:

- 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.

Example: A hospital inpatient experiences acute respiratory distress, and an in-house ED physician is called in. An anesthesiologist intubates the patient, but the ED physician is asked to oversee the management of the initial ventilator settings. The ED physician evaluates the patient and directs the ventilator setup and first-day ventilator management, which includes providing the service, reviewing the patient's chart, seeing the patient, writing notes, and communicating with other healthcare professionals and the patient's family.

On the claim, you would report 94002 for the ventilator management. Don't forget to append 518.82 (Acute respiratory distress) to 94002 to represent the patient's condition.

When choosing ICD-9 codes for ventilation assist and management services, you-ll typically report one that indicates respiratory distress, says Jill Young, CPC-EDS, CPC-IM, of Young Medical Consulting in East Lansing, Mich.

Payers won't usually have a set list of acceptable diagnoses for these services, "but respiratory failure and respiratory arrest are the most common ICD-9 codes accepted," Young says. The most common codes for respiratory failure and arrest are:

- 518.81 -- Acute respiratory failure

- 518.82 -- Acute respiratory distress

- 518.83 -- Chronic respiratory failure

- 518.84 -- Acute and chronic respiratory failure

- 799.1 -- Respiratory arrest.

Patients with breathing problems don't always require mechanical ventilation described by 94002 or 94003. Your physician might also provide the patient continuous positive airway pressure (CPAP) ventilation or continuous negative pressure (CNP) ventilation to intermittently facilitate breathing.

(Note: CNP is rarely used in the ED setting; you are much more likely to encounter CPAP claims when coding for ED patients.)

Report 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management) for CPAP or BiPAP (bilevel positive airway pressure), and 94662 (Continuous negative pressure ventilation [CNP], initiation and management) for CNP.

CPAP explanation: "CPAP is a technique of respiratory assistance that increases the functional residual capacity of the lung by expanding atelectatic areas within the lung," according to CPT Assistant Fall 1992.

Example: The ED physician is called into the coronary care unit for a patient in acute respiratory distress who was admitted for congestive heart failure. He examines the patient and decides to manage him with CPAP ventilation, and documents his orders for management of the CPAP.

You should report 94660 for the encounter. Don't forget to link 518.82 (Other pulmonary insufficiency, not elsewhere classified) and 428.0 (Congestive heart failure, unspecified) to 94660 to prove medical necessity.