Pulmonology Coding Alert

You can avoid losing over $100 for reporting ventilation therapy when your pulmonologist performed critical care, if you focus on the encounter notes. But when documentation supports only the ventilation management, you must choose a procedure code rather than the E/M, or you'll be overcoding the claim.

Let our experts show you which details to zoom in on for the most ethical and optimal ventilation management claims.

According to CPT, all of the ventilation therapy codes mentioned in this article (94002-94004, 94660, 94662) are bundled into E/M codes, meaning you cannot report ventilation therapy with an E/M service. When your pulmonologist performs 94002-94004, 94660 or 94662, you'll need to decide whether to report the ventilation therapy or roll the work into the E/M level, says Kent Moore, a healthcare financing and delivery systems manager in Leawood, Kan.

Notes for encounters in which the pulmonologist provides ventilation management will likely lead you to the proper code choice; if the pulmonologist focuses on ventilation management services during the encounter and does not document key components warranting an E/M, report a ventilation management code.

But if the notes describe an encounter in which the physician performs ventilation management during the course of a larger E/M, report the E/M code.

"So if an E/M service code, such as subsequent hospital care or initial hospital care, more accurately describes the service provided by the physician, you should report that code instead," Moore says.

Also, critical care codes may be more appropriate for the patient with acute respiratory failure in which the physician manages the respiratory failure as well as the underlying or related conditions.

Benefit: Choosing to report the E/M instead of ventilation management, when allowable, may benefit the practice's bottom line. The E/M codes typically associated with ventilation management codes (critical care, inpatient hospital care) require much more work and documentation, and they pay at a higher rate than the ventilation management codes.

"In most cases, if you did enough work to qualify for an E/M level, you would want to report the E/M," says Denae Merrill, CPC, coder for Covenant MSO in Saginaw, Mich.

Example: If you choose to report 94003 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day), but your physician provides services more in line with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), you'll miss out on deserved reimbursement.

The physician work relative value units (RVUs) for 94003 are 1.37, while the RVUs for 99291 are 4.50. So the reimbursement for 94003 is about $52, while 99291 pays about $170.

If your pulmonologist treats a patient solely with ventilation assist and management, you'll choose one of the following codes depending on the location of the service and the day of treatment, Merrill says:

• 94002 -- Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day

• 94003 -- ... hospital inpatient/observation, each subsequent day

• 94004 -- ... nursing facility, per day.

Consider this example: A hospital inpatient experiences acute respiratory distress, is intubated and needs ventilator assistance to breathe. The pulmonologist evaluates the patient and directs the ventilator setup and the patient's first-day ventilator management. On the claim, you would report 94002 for the ventilator management.

Don't forget to append 518.82 (Acute respiratory distress) to 94002 to represent the patient's condition.

Remember: The 94002 code includes "the pulmonologist providing the service, reviewing the patient's chart, seeing the patient, writing notes and communicating with other healthcare professionals and the patient's family/caregiver," Moore says.

Patients with breathing problems don't always require mechanical ventilation described by codes 94002-94004. Your pulmonologist also might provide the patient continuous positive airway pressure (CPAP) ventilation or continuous negative pressure (CNP) ventilation to intermittently facilitate breathing.

Report 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management) for CPAP or BiPAP (bilevel positive airway pressure), and 94662 (Continuous negative pressure ventilation [CNP], initiation and management) for CNP.

CPAP explanation: "CPAP is a technique of respiratory assistance that increases the functional residual capacity of the lung by expanding atelectatic areas within the lung," according to CPT Assistant Fall 1992.

The pulmonologist can provide CPAP via mask or endotracheal tube, with or without a ventilator. When CPAP is required for intermittent assistance, as in sleep apnea, report 94660.

Example: A 67-year-old patient with obstructive bronchitis and emphysema is seen in the hospital for increasing PaCO₂ levels in spite of therapy. The pulmonologist orders nocturnal BiPAP to treat the patient. In this instance, the ICD-9 codes would be 491.20 for the obstructive bronchitis and emphysema without acute exacerbation and 518.83 for chronic respiratory failure. On this claim, you should report 94660 for the encounter.

Physicians use CNP to give patients night-time respiratory muscle rest (for example, patients with COPD or neuromuscular disorders might need CNP). According to CPT Assistant Fall 1992, "CNP is usually not employed in the acute situation, but rather is used in chronic failure as a means of intermittent support."

Example: The pulmonologist evaluates a hospital inpatient with Guillain-Barre disease who is slowly recovering and has chronic respiratory failure. She decides the patient needs ventilatory assistance at night via a Cuirass ventilator. The pulmonologist orders the Cuirass ventilator, determines the ventilator settings for CNP, and evaluates the patient's breathing while on the ventilator.

On the claim, Merrill says, you should report 94662. Don't forget to append ICD-9 code 518.83 (Chronic respiratory failure) to 94662 to represent the patient's chronic respiratory failure and 357.0 (Acute infective polyneuritis) for the patient's Guillain-Barre disease.