Pulmonology Coding Alert

Watch out for NCCI bundles when your pulmonologist provides both E/M and vent services

You can avoid denials for your pulmonologist's respiratory failure treatments if you pay attention to your physician's method of ventilation management, the date of care, and whether Medicare bundles E/M codes into the services. By understanding three essential points, you're sure to choose the right ventilation management code (94656-94662) every time. 1. Choose a Management Code Based on Method 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.

The first and foremost documentation that the physician should include is the ventilator settings/adjustments, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. 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.

Once you know how your pulmonologist administered the ventilation, look at when he administered the treatment. Choose the correct code based on whether you're reporting the first day of ventilation or subsequent days.

None of these codes are time-based, and there are no documentation guidelines for any of these codes, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. If your pulmonologist just sets the patient up on the ventilator without giving input on any other aspects of the patient's treatment, you should use 94656 for mechanical ventilation.

Example: A patient has respiratory failure superimposed on congestive heart failure. Another physician calls your pulmonologist into the coronary intensive care unit to set up the patient, who has just been intubated, on a ventilator.

The pulmonologist examines the patient, reviews the pertinent data including chest x-rays, and orders the ventilator settings. He then writes a note describing what he's done, documenting all the ventilator settings and how to monitor the patient including measuring arterial blood gases.

You should report 94656 for the first day of the ventilation and 94657 for subsequent days. You should report 518.81 (Acute respiratory failure) for the acute respiratory failure and 428.0 (Congestive heart failure, unspecified) for the congestive heart failure.

Try this: If the pulmonologist initiates only continuous positive airway pressure (CPAP) on an intubated patient, you should select [...]