Pulmonology Coding Alert

Hint: Look at services provided and patient condition to arrive at right codes.

When your pulmonologist provides ventilation management services to a patient, you will need to turn to ventilation management service codes instead of an E/M code or a critical care code, as is the case usually. Let the scenarios and advice that follows point the way to accurate ventilation management coding.

Look at 94002-94003 for These Conditions

You can report 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day) and 94003 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day) for ventilation management services provided by your pulmonologist if the patient is already intubated and on the ventilator.

"The provider would report the ventilator management codes (94002-94003) when managing only the ventilator settings, and not treating any other clinical issues related to the care of the patient," says Mary Mulholland, MHA, RN, CPC, with University of Pennsylvania Health System in Philadelphia. "For the initial date of service CPT® 94002 would be reported." "If you were following a ventilator patient in the CCU and were not responsible for any other therapy on the patient, you would code 94003 for the subsequent day visits, rather than subsequent hospital care codes (99231-99233)," says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. "The documentation for 94003 is less rigorous than any of the hospital visit codes."

Example: A patient admitted to the MICU for congestive cardiac failure goes into respiratory failure. The ED physician summons the pulmonologist into the ICU after the patient has been intubated. The pulmonologist places the patient on a ventilator and orders appropriate ventilator settings. He documents the procedure that he has performed and the ordered settings and instructions about patient monitoring.

Since your pulmonologist did not perform any other services apart from ventilator management you will report the procedure that your pulmonologist performed using 94002 for the first day and 94003 for subsequent days.

Reach for Critical Care Codes Based on Patient's Condition

When your pulmonologist provides ventilator assist services along with other aspects of care to a critically ill patient, you can report the procedure using the more comprehensive critical care service codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 30-74 minutes of time spent on the patient and +99292 (Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes [List separately in addition to code for primary service]) for every additional 30 minutes of time spent in providing the services to the patient.

"If the pulmonologist is present and is required to actively manage problems other than ventilator management, he or she may opt to report the appropriate subsequent evaluation and management code (99231-99233) or critical care (99291-99292) depending upon the nature of the services provided and the time associated with the services," says Mulholland.

Follow critical care rules: To report critical care codes instead of ventilator management service codes, you need to remember that the patient's condition must fulfill guidelines laid down by CPT® regarding criticality. CPT® rules state that "critical care is the direct care provided by a physician to critically ill or injured patient" and "the critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition." CMS states that "Critical care services must be medically necessary and reasonable" to report any service provided to the patient using critical care codes. Time requirements must also be met.

Apply E/M Codes for More Comprehensive Services

If your pulmonologist performs a thorough evaluation in the form of assessment and examination of the patient and then decides to intubate the patient and place him on a ventilator to assist breathing and goes through other treatment options to stabilize the patient's condition, then you can use an E/M code 99222-99223 (Initial hospital care, per day, for the evaluation and management of a patient...) or subsequent hospital visit codes 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient...) instead of 94002-94003 to report the inclusive services performed.

Note: Usually E/M services provided to a patient who need ventilator management are of high level of evaluation, decision making and management. So you could be using a higher level of E/M code for reporting the complete service provided, if documented appropriately.

Use critical care codes (99291 and +99292) instead of an E/M code if the patient's condition is critical and has chances of causing a life-threatening situation.

Keep in mind: Remember that critical care codes are used based on patient's condition and the time (>30 minutes) spent providing care to the patient. If patient's condition does not comply with guidelines for criticality, you would use an E/M code.

Example: A patient presents to the hospital with moderate breathing difficulties. The patient has a prior history of emphysema and respiratory failure. The patient was in the habit of smoking in the past. Your pulmonologist reviews the patient's past history, assesses the patient's present symptoms, and tries to relieve the patient's airway by providing a short duration of inhalation therapy using a nebulizer. When this fails to relieve the breathing difficulty, your pulmonologist decides to intubate the patient and provide mechanical ventilation. Your pulmonologist spent a total of 75 minutes with the patient.

You have to report the services using the E/M code 99223, as your pulmonologist did more than just provide ventilation management services. You cannot use critical care codes as the patient's present condition cannot be termed "critical" as per CPT® guidelines.