Pulmonology Coding Alert

Question: What documentation is necessary when reporting vent management?

New Mexico Subscriber

Answer: In terms of documentation, the physician should record the ventilator settings and adjustments. This includes the initial or current vent settings, any changes to those, and recommendations and/or orders relating to the vent setting changes.

Once you know how your pulmonologist administered the ventilation, look at when he administered the treatment. Choose the correct code based on whether you’re reporting the first day of ventilation or subsequent days.

Example: A patient has respiratory failure superimposed on congestive heart failure. Another physician calls your pulmonologist into the coronary intensive care unit to set up the patient, who has just been intubated, on a ventilator.

The pulmonologist examines the patient, reviews the pertinent data including chest X-rays, and orders the ventilator settings. He then writes a note describing what he’s done, documenting all the ventilator settings and how to monitor the patient including measuring arterial blood gases.

You should report 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day) for the first day of the ventilation and 94003 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day) for subsequent days. Link the code to J96.00 (Acute respiratory failure, unspecified whether with hypoxia or hypercapnia) for the acute respiratory failure and I50.9 (Heart failure, unspecified) for the congestive heart failure, unless documentation supports more specific codes.

Remember this: If the pulmonologist initiates only continuous positive airway pressure (CPAP) on an intubated patient, you should select 94660 (Continuous positive airway pressure ventilation (CPAP), initiation and management). But if the physician initiates negative pressure ventilation, you should use 94662 (Continuous negative pressure ventilation (CNP), initiation and management). The most frequent use for 94660 is in the outpatient setting for the patient with sleep apnea on whom the pulmonologist initiates nasal CPAP to use during sleep.