Pulmonology Coding Alert

Bundling E/M services into your vent management codes is NOT the cure-all

When a pulmonologist cares for a patient in respiratory failure, he provides critical care services that may include invasive or noninvasive ventilation management. Follow these two tips before you submit your ventilation procedure claims to make sure you make the highest coding grade.

When your physician delivers an E/M service and initiates bilevel ventilation on a patient, report one or the other - but NEVER both.

Medicare considers ventilation management (94656-94662) as part of the critical care of an E/M procedure, says Jill Young, CPC, coding specialist with Young Medical Consulting LLC in East Lansing, Mich.

You can think of bilevel ventilation as a bridge between intubation and unassisted breathing, Young says. Pulmonologists institute bilevel ventilation for ventilatory assistance in patients with respiratory failure to avoid intubation and mechanical ventilation, she says.

Your decision should depend on the extent of the pulmonologist's activities during the visit and the available documentation. If he simply initiates ventilation and notes this activity, you should only report a ventilation management code. However, if the pulmonologist fulfills the requirements of documenting history, examination and decision-making, you can then report the appropriate level of E/M care (99221-99233, Hospital inpatient services).

Bottom line: Bill the service that takes precedence during the day. Critical care would take precedence over ventilation management. In most cases, E/M services take precedence over the ventilation management.

Make sure your documentation clearly states if the ventilation services were invasive or noninvasive.

Check your documentation for details on whether the patient was intubated or not to help you decide between the invasive and noninvasive ventilation techniques.

Invasive techniques require the pulmonologist to place an endotracheal tube with any of 20 different modalities of mechanical ventilation (ventilation machine). 

Coding solution: For invasive ventilation techniques, you should report 94656. The key in when to report 94656 lies in the definition, which states, "initiation of pressure or volume preset ventilators," says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

On the other hand, sometimes a pulmonologist will hook a mask onto a CPAP machine at home for certain conditions, such as sleep apnea. In this case, you should report 94660 (Continuous positive airway pressure [CPAP] ventilation, initiation and management).

94656 Provides a Coding Option for Noninvasive Techniques

Exception: But suppose the pulmonologist decides to use a noninvasive method to assist an elderly emphysema patient with acute respiratory failure. He hooks a mask onto a mechanical ventilator in the mobile intensive care unit (MICU). In this case, you should report 94656 because the patient had respiratory failure.  

Extra: You should not bill 94660 when the pulmonologist checks the pressure on a patient's CPAP machine, because you should only report 94660 when a pulmonologist initiates and manages continuous positive airway pressure ventilation.

But, if a nurse practitioner or physician assistant checks the equipment and reviews information with the patient, you should bill the appropriate E/M code (99211, Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problems[s] are minimal. Typically, 5 minutes are spent performing or supervising these services).

If the pulmonologist saw the patient on the same day that he or other staff checked the equipment, he could bill an E/M service for his visit but not for the respiratory therapist's work. If the therapist checked the equipment, and the physician did not see the patient, you could not bill for this service.