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Pulmonology Coding Alert

Let Expert Solutions Revive Your Failed Ventilator Claims

Published on Mon Feb 23, 2004

Get a grip on billing E/M codes and ventilator services

Are you getting repeated denials for your ventilator management or critical care claims? If so, our experts offer quick-fix solutions to three common errors that coders make when reporting 94656 or 99291.

The following problems are examples of incorrect coding. The solutions provide ways to correctly report the services.

Problem: You submitted 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) because the pulmonologist put the patient on a ventilator.

Solution: When you report critical care codes (99291-99292), make sure the pulmonologist's documentation supports CPT's guidelines for critical care services. Before you assign another critical-care code, remember:

  •  CPT defines a critical illness or injury as one that impairs one or more vital organ systems. This creates a high probability of imminent or life-threatening deterioration in the patient's condition. You can't use 99291-99292 because the patient is in the critical care unit. The patient must have a critical illness, such as anaphylactic shock (995.0), or you'll have to use other E/M codes (for example, initial hospital care codes 99221-99223), says Roger Hettinger, CPC, CMC, CCS-P, coding specialist at Sioux Valley Clinic in Sioux Falls, S.D.

  •  Critical care involves high-complexity decision-making the physician uses to assess, manipulate and support vital system function(s). In critical care, the physician treats single or multiple vital organ system failure(s) and/or prevents further life-threatening deterioration of the patient's condition for at least 30 minutes, Hettinger says.

    Tip: You can add treatment time the physician provides at different intervals during the day. But the time must be a cumulative representation of the physician's efforts on a given calendar day.
                                 
  •  What if you review the documentation and find that the physician treated the patient for less than 30 minutes? If documented correctly, you could report either a high-level E/M code, such as 99215, or a ventilator management code (for example, 94656 - Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day).

    Problem: You report 94660 (Continuous positive airway pressure [CPAP] ventilation, initiation and management) in addition to 99291 (Critical care ...) or 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) for your pulmonologist's ventilator management.

    Solution: Medicare bundles ventilation management and E/M codes, Hettinger says. Therefore, you should assign the one code that the physician's documentation clearly supports. For instance, if you want to report 94660, make sure the doctor's progress note identifies the physician's initiation of the ventilation service in addition to any other pertinent clinical information. Typically, you assign 94660 when the doctor places a mask on the continuous positive airway pressure ventilation machine.

    Problem: The pulmonologist begins ventilation management on one day, and then applies the same treatment the following day. You report 94656 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day) for both days of care.

    Solution: Remember to list 94656 only for the first day of ventilation treatment. When the physician uses the same treatment after the first day, you must report 94657 (... subsequent days), Hettinger says.

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