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Pulmonology Coding Alert

Master Coding Techniques When Billing for Ventilator Management

Published on Mon Apr 01, 2002

A pulmonologist provides 40 minutes of bedside ventilator management to a patient in the intensive care unit of a hospital. This means he or she can bill for critical care services, right? Not necessarily.
 
Critical care codes (99291-99292) may be used if a long list of "ifs" is met. Otherwise, there are other billing options, such as ventilator management (94656-94657), the appropriate level of inpatient hospital services (99221-99223), or initial consultation services (99251-99255).

Don't Make These Four Mistakes

When caring for Medicare patients on ventilators, don't:
 
1. Use a critical care code simply because a patient is on a ventilator. The patient must meet CPT and CMS requirements for critical care.
 
2. Bill ventilator management separately from a critical care or E/M service.
 
3. Include procedures billed separately (e.g., thoracentesis, cardiopulmonary resuscitation [CPR]) as part of the critical care time used to bill the critical care code.
 
4. Bill a level-three E/M code for a stable patient just because he or she is on a ventilator. A detailed history or exam or medical decision-making of high complexity (two of these three components) is required to bill a level-three code.

Patient Must Meet Critical Care Guidelines

Critical care codes reimburse at a high rate. "Physicians and coders must understand the guidelines outlined in CPT and review these before billing," says Deborah Grider, CPC, CPC-H, CCS-P, coding specialist and president, Medical Professionals Inc. in Indianapolis. According to CPT, critical care is the direct delivery by a physician of medical care for a critical illness or injury that acutely impairs one or more vital organ systems to the extent that there is a "high probability of imminent or life-threatening deterioration in the patient's condition." This definition applies whether or not a patient is having a medical emergency.
 
Critical care involves high-complexity decision-making to assess, manipulate and support vital system functions to treat single or multiple vital organ system failure and/or prevent further life-threatening deterioration of the patient's condition. Examples of vital organ system failure include shock, or central nervous system, circulatory,  renal, hepatic, metabolic and/or respiratory failure.

Billing Critical Care Codes

Ventilator management is bundled into 99291-99292 if the visit meets the billing threshold for time spent with the patient. To use 99291, the pulmonologist must spend 30 minutes or more with the patient. Code +99292 is billed for visits that exceed 74 minutes. This code is an "add-on" code and must be used with 99291.
 
To use these codes, however, the physician must devote his or her full attention to the patient during the time counted as the critical care service, although the time does not have to be continuous. Billable time is defined as anything from immediate bedside care to patient-related activities, such as reviewing test results, documenting services in the medical record, and discussing the case with staff, family members or surrogate decision-makers. When billing critical care codes for a patient requiring ventilator management, the physician should document the total amount of time spent providing service at the bedside and on patient-related activities. It is important to document signs and symptoms that validate that the critical care guidelines are met, such as organ deterioration and interval assessments of the patient.

Billing for Separate Procedures

According to Grider, a common coding error is to report ventilator management separately; it is included in the critical care code. In addition to ventilator management, the following services are also included:

 
  • Interpretation of cardiac output measurements (93561-93562)
     
  • Chest x-rays (71010, 71015, 71020)
     
  • Pulse oximetry (94760-94762)
     
  • Blood gases and information data stored in computers (e.g., ECGs, blood pressures, hematologic data [99090])
     
  • Gastric intubation (91105)
     
  • Temporary transcutaneous pacing (92953)
     
  • Vascular access procedures (36000*, 36410*, 36415*,
        36450, 36600*).

    • Time spent on procedures such as thoracentesis (32000*-32002) or CPR (92950) cannot be included in the critical care time, adds David McKenzie, director of reimbursement for the American College of Emergency Physicians in Irving, Texas. In this case, modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to the critical care code. Some third-party payers may not recognize this modifier, so check with individual carriers.
     
    "When billing separate procedures, the pulmonary physician must use an ICD-9 code to justify their medical necessity," Grider says, "which is not necessarily the same diagnosis code used to justify the patient visit." For example, you may code staphylococcus pneumonia (482.4), while the code to justify insertion of a chest tube (32020) is pleural effusion (511.9). If the total procedure time for the chest tube insertion is 10 minutes, and the "total floor time" for the physician's services (including the chest tube insertion) for the care of the critically ill patient is 45 minutes, the procedure time must be subtracted from the "total floor time" to report the critical care time appropriately. This leaves 35 minutes that can be reported for the critical care services, which exceeds the 30-minute minimum threshold. Therefore, bill 99291 in addition to 32020. Append modifier -25 to the critical care code to identify that a separate E/M (critical care) service was provided on the same day as a procedure or other service (e.g., chest tube insertion).

    Other Billing Options

    "If the physician does not see the critically ill patient on a ventilator for the threshold amount of time (30 minutes) required to bill a critical care code, use the ventilator management codes," McKenzie says.
     
    Documentation requirements for ventilator management vary based on how the service is billed. Physicians may bill for ventilator management of the patient who does not meet critical care guidelines using 94656-94657, or E/M codes. "When billing ventilator management, the key components (history, exam and medical decision-making) do not need to be documented as otherwise required for E/M services," says Mary Mulholland, RN, BSN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia.
     
    The documentation requirements for submitting a claim for ventilator management are straightforward, Mulholland says. "CMS considers ventilation management a medical decision-making function. Documentation for 94656 should include comments leading to the decision to mechanically ventilate the patient, in addition to the ventilation settings chosen by the provider. The provider may also wish to comment on the patient's response to mechanical ventilation," she adds.
     
    When reporting 94657, document the patient status ventilator settings, including comments on whether changes must be made to these settings, and why these changes are necessary, Mulholland suggests.
     
    The physician may not bill a ventilator management code in addition to an E/M code because the former is included in the E/M service. The physician can bill a daily visit E/M code, as either the primary physician (99221-99233) or as a consult (99251-99255). If he or she is consulted a second time during the stay, the consultant bills 99261-99263 (follow-up consult).

    Billing E/M Codes with Critical Care Codes

    If an elderly patient is seen by the pulmonologist early in the day for an E/M service for influenzal bronchopneumonia (487.0) and is moved to the ICU that evening for acute respiratory failure (518.81) and requires mechanical ventilation, bill an E/M and critical care code on the same date of service, Mulholland says. For example, the physician evaluates a patient on morning rounds and reports 99233 (level-three E/M service). Later that evening, the patient's condition worsens, and the physician provides critical care services. "Bill the critical care time as well as the E/M service, and append modifier -25 to the E/M code. Each service should have a different diagnosis code. The E/M is linked to 487.0, and the critical care is linked to acute respiratory 518.81," she says. 
     
    However, do not bill an E/M service and critical care code if the critical care service came first. "All of the subsequent services would be rolled into the critical care service performed earlier in the day," Mulholland says.
     
    Note: Any physician may use critical care codes regardless of specialty. However, only one physician per specialty (e.g., pulmonary) may report them per day. Insurers do not consider it reasonable to have two pulmonolgists render critical care services on the same day. The pulmonologist who is qualified to manage the critically ill/injured patient should be able to tend to all pulmonary care. Additionally, two specialists (e.g., a pulmonologist and a cardiologist) cannot bill for the same critical care hour (e.g., 9 a.m.-10 a.m.). The times that are reported for each specialist should not overlap.

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