Internal Medicine Coding Alert

Question: Another physician is treating a patient who has acute respiratory failure superimposed on congestive heart failure. The treating physician called our internist into the coronary intensive care unit to set up the patient, who had just been intubated, on a ventilator. The internist examined the patient, reviewed the pertinent data including chest x-rays, and ordered the ventilator settings. He then wrote a note describing his actions, documenting all the ventilator settings and describing how to monitor the patient. The ventilation lasted three days. How should I code this encounter?

Minnesota Subscriber

Answer: For the first day of the ventilation, report 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day).

To represent the next two days of ventilation, report 94003 (... hospital inpatient/observation, each subsequent day) x 2.

You cannot report ventilation management with E/M services. If the physician provides an E/M service on the same day as the management, the ventilation management is bundled with the E/M services.

Don't forget: Coders should count the ventilation management in the medical decision-making portion of the E/M.

Also, attach ICD-9 codes 428.0 (Congestive heart failure, unspecified) and 518.81 (Acute respiratory failure) to 94002 and 94003 to represent the patient's cardiac and respiratory issues.