Pulmonology Coding Alert

Question: If our pulmonologist is the primary physician for a hospitalized patient who is on a ventilator, can we bill for ventilation care using 94657 and a daily hospital care code on the same day?

Arizona Subscriber

Answer: Ventilator management codes 94656 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day) and 94657 (... subsequent days) can never be billed with an E/M code. In fact, it is part of HCFAs Correct Coding Initiative.

HCFA assumes that whatever E/M activities are part of managing a patient on a ventilator are included in the ventilator management code. Similarly, if E/M activities are performed for a patient on a ventilator, HCFA assumes the E/M code covers all management of the patient, including the ventilator care.

The choice for the coder in this case is either 94657 or a subsequent hospital care E/M code in the 99231-99233 range. Whether the visit is coded as ventilator management or an inpatient E/M depends on the extent of the physicians activities during the visit and the documentation of them. If the physician simply checks a hospitalized patient on a ventilator and indicates in the medical record that the patient is continuing on a ventilator, the choice should be 94657. If the physician fulfills the requirements of documenting history, examination and decision-making during the daily hospital visit while also managing the patient on a ventilator, an inpatient E/M code should be used because the management activity would be considered bundled into the E/M.

Documentation of history, examination and decision-making is not required when using 94657. However, it is not always prudent to use it for managing ventilator care of a hospitalized patient. Although payment can vary in different regions of the country, 94657 generally pays a few dollars less than a level-two subsequent hospital care E/M code, but more than a level one. So, if the physician can justify a level-two E/M daily hospital visit, and completes the documentation requirements of that visit, the level -two E/M code would result in greater reimbursement than 94657.


Reader questions answered by Walter J. ODonohue Jr., MD, FCCP, FACP, a representative to the AMA CPT Advisory Committee for the American College of Chest Physicians (ACCP) and CPT/RUC Committee chairman of the ACCP; and Carol Pohlig, RN, CPC, a reimbursement analyst for the office of clinical documentation in the department of medicine at the University of Pennsylvania in Philadelphia.