Pulmonology Coding Alert

Question: Our pulmonologist oversaw vent management for an inpatient last week and billed it as critical care, but the documentation doesn’t support the requirements for billing this way. He said the documentation of vent management will be enough to justify the 99291 coding. Is this true?

Michigan Subscriber

Answer: No, it isn’t. Do not make the mistake of reporting critical care services simply because the patient is on a ventilator or in the intensive care unit. The patient must meet all of the requirements for critical care from both CPT^® and from the insurer’s policy requirements.

In brief, the patient must have 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.” Since respiratory failure meets this definition, the next factor you consider is the physician’s cumulative time spent on the floor, unit, and bedside performing activities directed toward the patient. Report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 30 to 74 minutes, and +99292 (… each additional 30 minutes (List separately in addition to code for primary service) to reflect each unit of 30 minutes beyond that first 74 minutes.

When the patient is critically ill but the time spent with them is less than 30 minutes, you should report a hospital inpatient service (99221-99233) or ventilation management (94001-94004) code. Monetarily, it may be more beneficial to report an E/M code than the ventilation management code when documentation supports the E/M level.

The first day, a patient is often on ventilation and requires critical care services, but since you cannot bill for both on the same day, most practices will report 99291, assuming all criteria are met for critical care services. If all you are doing is managing the ventilator, and no other interventions are delivered to minimize the critical nature of the patient, report vent management and not critical care.

When you report critical care codes, do not also bill for ventilation management. CPT^® includes vent management in the critical care codes. Time spent with ventilation management can be counted toward critical care because you are not billing separately for the service.