Pulmonology Coding Alert

We'll show you when to use 94656

You can avoid denials for the pulmonologist's respiratory failure treatments if you report ventilator management (94656-94662) based on the physician's method and time of care, and whether Medicare bundles E/M codes into the services.

Experts answer three of your most common ventilation coding questions:

Question 1: Which ICD9 Codes can we use for respiratory failure?

You have three diagnosis codes to choose from when reporting respiratory failure:

 518.81 - Acute respiratory failure

 518.83 - Chronic respiratory failure

 518.84 - Acute on chronic respiratory failure

Linking the right ICD-9 code to a procedure code can be tricky. Sometimes pulmonologists use the term "respiratory failure" as a "catchall" phrase when a patient has difficulty breathing, says Charlie Strange, MD, FCCP, a physician at the Medical University of South Carolina in Charleston. In other words, you could use 518.81 for acute respiratory failure, although the physician actually intended you to assign 518.84 for chronic failure, he adds.

Smart idea: The key to using the right diagnosis code for respiratory failure is knowing how quickly the patient normalizes his lung function between episodes of the respiratory disease, Strange says.

Example: Your pulmonologist treats a patient with end-stage emphysema who has consistently altered carbon dioxide and oxygen levels. The physician diagnoses the oxygen-dependent patient with chronic respiratory failure (518.83). The patient presents in the emergency department for an exacerbation of emphysema, which severely deteriorates the patient's already compromised condition, causing acute respiratory failure. In this case, you would report 518.84 for acute on chronic respiratory failure.

Question 2: How should we code ventilation management procedures?

When your physician uses ventilation management to treat respiratory failure, you should choose from the following codes:

 94656 -- Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day

 94657 -- ... subsequent days

 94660 -- Continuous positive airway pressure (CPAP) ventilation, initiation and management

 94662 -- Continuous negative pressure (CNP) ventilation, initiation and management

Tip: You should know the physician's method for administering ventilation management to pick the right procedure code, coding experts say.

Suppose the pulmonologist applies a noninvasive ventilation method to assist an elderly emphysema patient with acute respiratory failure. The physician hooks a mask onto a mechanical ventilator in the mobile intensive care unit (MICU).

In that case, you should report 94656 for the first day of "initiation of pressure or volume preset ventilators ..." For subsequent days, you should assign 94657, says Victoria O'Neil, CPC, CCS-P, a compliance coordinator who specializes in pulmonary issues in St. Louis.

"The documentation should provide a brief assessment of the patient's current condition," O'Neil says. This includes the initial or current vent settings, any changes to those parameters (for example, titration of peak-end expiratory pressure [PEEP] to keep FiO2 low), and recommendations and/or orders relating to the vent setting changes, she says.

Try this: When the physician applies the mask to a continuous positive airway pressure ventilation machine to check for positive airway pressure, you should select 94660, O'Neil says. But if the physician is looking for negative pressure, you should use 94662.

Bonus: Knowing how to report these services could mean extra revenue for your practice. For instance, Medicare pays $100 for 94656 per allowable ventilation management session, according to national averages. Furthermore, when you report 94657, you can expect about $75.

Question 3: When our pulmonologist visits a patient undergoing acute respiratory failure in the MICU, he initiates mechanical ventilation for the patient. Should we report 94656 along with the appropriate hospital care code (99221-99233)?

Because of National Correct Coding Initiative edits, you can never bill ventilator management with an E/M code, such as 99221 (Initial hospital care ...) or 99291 (Critical care ...), O'Neil says.

The bottom line: You should choose either the E/M or the ventilation management depending on the physician's documentation.

"Usually, the physician's documented level of assessment and decision-making will justify billing an E/M code rather than simply vent management," O'Neil says.