Pulmonology Coding Alert

Whether you should use the ventilation management codes or the continuous positive airway pressure (CPAP) codes depends on the clinical intent and the patients underlying disease or medical necessity, according to Scott Manaker, MD, interim associate chair of clinical affairs and director of clinical documentation in the department of medicine at the University of Pennsylvania in Philadelphia. It isnt always a simple, straightforward decision, though, and sometimes an evaluation and management (E/M) code is the correct choice.

Fifteen years ago it was very simple, Manaker says. A patient in acute respiratory failure (518.81) was intubated and a mechanical ventilator was used to blow air. If respiratory failure was chronic (518.83), the physician used a positive-pressure ventilator. If the patient had obstructive sleep apnea (780.57), a CPAP machine was in order. Three clear clinical scenarios, three clear CPT Codes , and three clearly different ways of moving air for the patient:

94662 (continuous negative pressure ventilation [CNP], initiation and management)
94660 (continuous positive airway pressure ventilation [CPAP], initiation and management)
94656 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day) and 94657 (subsequent days)

Manaker says that many payers will reimburse ventilator management 94656 and 94657 only when the patient is in the hospital, not at home, because they view 94656 and 94657 as intended only for the acutely ill patient. For a chronically ill outpatient they want you to use code 94660, which means you are doing some type of home visit which most physicians dont do to manage that ventilator.

NIPPV vs. CPAP

Today, technology and creative medicine have eliminated the need for an invasive procedure for the patient with acute respiratory failure but have also made correct coding more difficult. Manaker says that in a postpayment review of a patient in acute respiratory failure who is being ventilated with a noninvasive positive pressure ventilator (NIPPV) machine, some insurers want to pay for only CPAP, not ventilation management. I would say thats wrong. It wont come up in a prepayment level, only in postpayment review, but certainly physicians worry about it. He says an NIPPV can be used appropriately for acute respiratory failure, chronic respiratory failure, vent management or obstructive sleep apnea.

If Im using a CPAP mask, but in conjunction with a mechanical ventilator for acute respiratory failure, and clearly the clinical intent is to provide full mechanical ventilatory support, it is correct and proper to use the vent-management code, Manaker says. He cites an example of a patient with chronic respiratory failure from polio who doesnt need continuous ventilation but does need nighttime ventilation. The physician chooses a NIPPV machine with a tightly fitting face mask, to be used only at night. You are clearly providing respiratory support, and it is reasonable to code that as vent management, he says.

The NIPPV machine and a face mask can also be used to fully ventilate an acutely ill patient, because it has a respiratory rate and both an inspiratory and an expiratory pressure rate. Again, the intent is to provide full mechanical ventilatory support for an acutely ill patient, and 94656 and 94657 are the appropriate codes to use.

Clinical Examples

Whats the correct thing to do when pulmonary patients are admitted to the hospital for another reason? For example, a patient with some type of muscle disorder is on a nighttime ventilator with a face mask and is admitted to the hospital for a urinary problem. When the pulmonologist is asked to see the patient and manage the nighttime ventilator, I would say that he is managing chronic respiratory failure and should therefore use the vent management codes 94656 and 94657.

What about the patient with obstructive sleep apnea, using a NIPPV machine, who is admitted to the hospital for a non-respiratory problem? Manaker says that in that scenario, even though the NIPPV machine and face mask are the same as in the prior example, the correct code to use is 94660 because the underlying diagnosis is obstructive sleep apnea and the intent is to use the ventilator to treat the obstructed airway.

Sometimes an E/M Code Is Correct

According to Margaret Stewart, RHIA, of Morgan Stewart Consulting in Norcross, Ga., the AMA says you can use the mechanical ventilation codes for other types of ventilation. Stewart says that pulmonologists need to choose between using the 94656 and 94657 vent management codes and an E/M code for services performed on the same day. Using both vent-management codes and an E/M code with a modifier-25 will cause the claim to be rejected, she says.

Carol Pohlig, BSN, RN, CPC at the University of Pennsylvania department of medicine in Philadelphia, says to be aware of which service you intend to report (vent management vs. E/M codes). Consider the following as an example:

99231 (subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem focused interval history; a problem focused examination; a medical decision-making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patients hospital floor or unit.)

99232 (requires at least two of these three key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision-making of moderate complexity. responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patients hospital floor or unit.)

99233 (requires at least two of these three key components: a detailed interval history; a detailed examination; medical decision-making of high complexity. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patients hospital floor or unit.)

Pohlig points out that code 99231 pays less than vent management, 99232 pays more than 94657, but not more than 94656, and 99233 pays more than both vent-management codes. Choose the codes carefully to be paid as much as you are due, and avoid denials.