Pulmonology Coding Alert

Question: Through a recent denial I learned that I cannot report both a ventilation therapy and an E/M code for the same patient on the same day. How do I determine which to report if the pulmonologist provides both services?

Tennessee Subscriber

Answer: Base your code choice on the encounter notes. If the pulmonologist focuses on ventilation management services during the encounter and does not document key components warranting an E/M, report a ventilation management code.

Alternatively, if the notes describe an encounter in which the pulmonologist performs ventilation management during the course of a larger E/M, report the E/M code. According to CPT, all of the ventilation therapy codes (94002-94004, 94660, 94662) are bundled into E/M codes, meaning you cannot report ventilation therapy with an E/M service.

Critical care codes (99291-+99292) may be most appropriate for a patient with acute respiratory failure in which the physician manages the respiratory failure with ventilation therapy in addition to attending to underlying or related conditions.

Benefit: Choosing the E/M code over the ventilation management code, when allowable, may benefit the practice's bottom line. The E/M codes typically associated with ventilation management codes (for instance critical care, 99291-99292, and inpatient hospital care codes, 99221-99223) require much more work and documentation from the pulmonologist, and they pay more than the ventilation management codes.

Key: So if your pulmonologist does the work to qualify for an E/M level, report the E/M.

Example: If you choose to report 94003 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day), but your physician provides services more in line with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), you'll miss out on deserved reimbursement ($253.91 for 99291 versus $63.48 for 94003).