Internal Medicine Coding Alert

Question: I have a tough coding choice to make. The internist performs initial-day ventilation management on a patient, but notes also indicate the physician provided critical care service. What is the best way to code this encounter?

Missouri Subscriber

- --Answer: Your best bet is to go with the critical care if the physician performed all of the components presented in the code descriptor.

------CPT bundles all the ventilator management codes (94002-94004, 94660, 94662) into critical care, so you cannot file 99291 (Critical care, E/M of the critically ill or critically injured patient; first 30-74 minutes) and a ventilator management code on the same claim. The decision you'll need to make is whether to report 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day) or the critical care code.------

Do this: Check the notes; if the physician focused solely on ventilator management services during the session, consider 94002. But if the notes describe an encounter in which the physician performs ventilation management in the course of a larger critical care service, report 99291.