Pulmonology Coding Alert

Question: A patient was seen by three different physicians on the same date of service. Two of the physicians billed daily services, but the third physician billed 94657 because he performed the ventilation management. All three physicians saw the patient for different reasons, and the ICD-9 codes reflect this. Medicaid indicates that 94657 has not been a billable code since 2001. Rather, it is a current CPT code. The only information I can find is that it is not billable when billing a critical care code because 94657 is bundled into the critical care code. Would you please explain how I should report this code?

New Mexico Subscriber

Answer: There is no national policy that Medicaid will not pay for 94657 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; subsequent days) or 94656 (... first day), ventilation management codes. However, states administer Medicaid, and each state has its own rules for reimbursement.

For example, in Georgia, Medicaid will not reimburse for the ventilation management codes, even though Medicare and other third-party payers will.

Insurers following the National Correct Coding Initiative do not allow you to bill a visit code or a critical care code with a ventilation management code because the ventilation management is bundled into these services.

If the three physicians report services under the same group number, payers may deny two of the services for the same date. Some contractual arrangements prevent reimbursement for inpatient services provided by different groups. You should check with you local insurer for more specific guidelines.