Medicare Compliance & Reimbursement

These tips help you identify higher paying critical care versus emergency department E/M codes.

If you fail to identify critical care documentation in encounters involving ventilation management, you could cut more than $130 from the claim.

Check out this expert advice on deciding whether you should report the service with an E/M code or one of the specific ventilation codes.

As more ED groups venture into engagements to provide hospitalist coverage, coding smarts for ventilation management are becoming vital.

When encounter notes indicate that the ED physician focused solely on mechanical ventilation services, you should choose from the following codes, confirms Steve Verno, NREMTP, CMBSI:

• 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.

Key: Report ventilator management "when the purpose of the visit centers [only] on ventilation assistance for adjustments in volume and pressure of the mechanical ventilator," says Verno, director of reimbursement at Emergency Medicine Specialists in Hollywood, Fla. The intraservice physician work for ventilation management includes the following items:

• reviewing the patient's chart

• meeting with the patient

• writing notes

• communicating with other healthcare professionals, and the patient's family or caregiver.

Example: The hospitalist responds to several calls over the course of a day to review blood gases and evaluate a patient with regard to changes in ventilator settings. This is the second day the patient is on the ventilator. All the work relates to managing the patient's ventilator status, and the hospitalist does not perform any further E/M service. In this example, report 94003 for the service.

CPT bundles ventilation management with all of the E/M codes (99201-99499), meaning that you cannot report both for the same patient encounter. If the physician performs vent management in the course of a larger E/M service, you should report the E/M instead.

Why? Base your code choice "on the level of decision making the physician documents," Verno recommends. If the ED physician performs components of an E/M service (history, exam, medical decision making [MDM], counseling) beyond what ventilator management requires, report the E/M code and not the ventilator management code, says Verno.

Example: A 65-year-old patient with acute airflow limitation due to chronic bronchitis and emphysema presents with very low oxygen saturation levels. The physician performs a history and physical exam. He orders labs to evaluate the possibility of an acute myocardial infarction and to gauge the degree of impending respiratory failure. After reviewing the medical record and the blood gases, the physician decides to intubate the patient. Subsequent to intubation, the physician orders specific ventilator settings.

The physician spends 42 minutes outside of the emergent intubation time caring for the patient. In this instance, you would report critical care (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and intubation (31500, Intubation, endotracheal, emergency procedure), but not ventilator management.

Benefit: Spotting critical care documentation -- and reporting 99291, rather than ventilator management code 94002 -- results in $133 more pay. The Medicare Physician Fee Schedule assigns 99291 5.90 transitional facility total relative value units (RVUs), which equals approximately $225 Code 94002 has 2.42 RVUs, or nationally pays approximately $92 per encounter.

The physician may also provide some patients with continuous positive airway pressure (CPAP) or continuous negative pressure (CNP), says Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

Report 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management) for CNP, which rarely occurs in the ED.

You'll be able to report critical care for many patients that require CPAP or CNP -- if the critical care time exceeds 30 minutes.

While you'll often see ICD-9 codes for respiratory distress or failure appended to ventilation management codes (94002, 94003, 94660, 94662), they might not be the only diagnoses that prove medical necessity for the physician's service, says Contreras.

"While [respiratory failure] codes are typically seen with the ventilation initiation and management services, there are several other conditions that are equally acceptable. It is important to check with your payers for any payer-specific policy restrictions," Contreras tells Eli.