EM Coding Alert

Learn the rules for vent management and E/M coding.

There are several common coding mistakes coders make when reporting ventilation management.

Find out ways to sidestep those mistakes and what you should do to avoid a claim denial for this common problem and other related services.

Tip 1: For Management Codes, Consider Location and Time Spent

If your provider uses ventilation management for respiratory failure treatment in a nursing home or in an inpatient or observation setting, you’ll 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)
• 94004 (… nursing facility, per day)

Scenario: A patient experiencing acute hypoxemic respiratory failure (AHRF) due to an acute pneumonia infection is intubated and placed on a ventilator in the intensive care unit (ICU).

You’ll report 94002 for the first day of ventilation and 94003 for any subsequent days. You’ll also link to J96.01 (Acute respiratory failure with hypoxia) for the AHRF and J18.9 (Pneumonia, unspecified organism) for the pneumonia infection, unless the provider’s documentation supports more specific codes.

Double-check the documentation: The provider needs to record several items in the documentation for ventilator management services. These items include ventilator settings and adjustments, such as the initial or current ventilator settings, what changes (if any) have been made, and recommendations or orders pertaining to the ventilator setting changes.

“Additionally, it’s best practice for the provider to document how the patient is responding to treatment and any diagnostic tests, records, or discussions that were reviewed during the visit,” says Jennifer Connell, BA, CPPM, CPCO, CDEO, CPMA, CPB, CRC, COC, CPC, CPC-P, CPC-I, CCC, CCVTC, CEMC, CENTC, CFPC, CGIC, CGSC, CHONC, CUC, ROCC, CEMA, CMCS, CMRS, AAPC Approved Instructor, revenue cycle director for Citizens Medical Professionals in Victoria, Texas.

Tip 2: Choose an E/M or Vent Management Code

If the provider performs an evaluation and management (E/M) service and ventilator management, you’ll need to carefully review the provider’s documentation to see which code to report. This is because E/M and ventilator management codes cannot be reported together per the National Correct Coding Initiative (NCCI) edits.

According to the 2023 National Correct Coding Initiative Policy Manual for Medicare Services, Chapter XI, Section J.5, CPT^® codes related to ventilation management, such as 94002-94004 and 94660-94662, “are not separately reportable with E/M CPT^® codes. If an E/M code and a ventilation management code are reported, only the E/M code is payable.”

At the same time the parenthetical note under the ventilator management codes state, “Do not report 94002-94004 in conjunction with evaluation and management services 99202-99499.”

“While ventilator management is not separately reportable, the vent management work should be included in the E/M code selection,” Connell says. The E/M codes that would typically include ventilation management services include:

• High-level emergency department visits, such as 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making)
• Critical care services, such as 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes (List separately in addition to code for primary service))

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Tip 3: Demonstrate Medical Necessity With Dx Code

You’ll need to show the medical necessity for the ventilator use to receive proper reimbursement. Without a proper diagnosis code, your claim is likely to receive a denial. However, sometimes the provider’s terminology may not clearly indicate the exact diagnosis. By carefully examining the documentation, you can figure out which code is the best option for your claim.

Scenario: A provider admits a patient experiencing respiratory failure to the hospital, and the patient is placed on a ventilator. The patient remains on the ventilator for five days. The provider documented the patient’s diagnosis as “respiratory failure.”

The diagnosis in the scenario is insufficient and should include more information regarding the respiratory failure. “Providers should document to the highest level of specificity for any given encounter,” Connell says. Using respiratory failure as an example, the provider’s documentation should specify if the condition is:

• Acute, chronic, or acute on chronic
• With hypoxia, hypercapnia (or hypercarbia), or hypoxia and hypercapnia

Each of these added details points to a different code that will show the medical necessity for the 94002-94004 service. If the provider in the scenario documented the patient’s diagnosis as acute or chronic respiratory failure with hypoxia, then you’d assign J96.21 (Acute and chronic respiratory failure with hypoxia).

“A general term, such ‘respiratory failure’ codes to an unspecified ICD-10-CM code (J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia), which may not meet a payer’s medical necessity requirements. Many payers have claim edits in place to automatically reject a claim billed with an ‘unspecified’ code,” Connell adds.

Furthermore, the medical documentation should also include whether the respiratory failure is caused by an underlying etiology or infection, such as heart failure, lung cancer, COVID-19, or pneumonia. Respiratory failure can also be caused by other contributing factors like tobacco use, abuse, or dependence, which should be recorded in the documentation, as well. This information is important for the provider to include in the documentation since it completes the patient’s medical record to ensure the patient receives proper care, but also underlying conditions and infections can affect which codes you assign.