Pulmonology Coding Alert

Higher level E/M pays more than vent management; don't lose out on the potential $221.

When you're lost between reporting a ventilation assist code and an E/M, don't look any farther. The encounter notes could provide you the answers you want. But first, you should resolve the question, "Does the physician provide ventilation assist only, or ventilation services during the course of a more comprehensive E/M service?"

Here are 3 guidelines to solving the puzzle.

1. Vent Therapy or E/M?

CPT bundles ventilation therapy codes 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day), 94003 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day), 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management), 94662 (Continuous negative pressure ventilation [CNP], initiation and management) into E/M codes. This means you cannot report ventilation therapy with an E/M service.

What to do: Remember these two items when choosing between two services:

1. If the physician focuses on ventilation management services during the encounter and does not document key components warranting an E/M, report a ventilation management code only.

2. But if the notes describe an encounter in which the physician performs ventilation management during the course of a larger E/M, report the E/M code. Make sure you report a medically necessary E/M over ventilation management. You would need to submit more documentation to support it, but the service would pay at a higher rate than the ventilation management codes for the increased service effort -- if approved.

Example: Your physician provides and documents services in line with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). You should choose to report 99291 instead of 94003, or will miss out on about $155 in work values.

Cost: The physician work relative value units (RVUs) reimbursement for 94003 is about $66 (1.37 RVU multiplied by 36.8729 conversion factor), while 99291 pays about $220.87 (4.5 RVU multiplied by 36.8729 conversion factor).

2. What's the Patient's Status?

If your physician treats a patient solely with ventilation assist and management, you'll choose one of the two ventilation management codes depending on the day of treatment: 94002 and 94003, says Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

Example: A hospital inpatient experiences acute respiratory distress, and an inhouse pulmonologist is called in. An anesthesiologist intubates the patient, but the pulmonologist is asked to oversee the management of the initial ventilator settings. She evaluates the patient and directs the ventilator setup and first-day ventilator management, which includes providing the service, reviewing the patient's chart, seeing the patient, writing notes, and communicating with other healthcare professionals and the patient's family. In this case, you would bill 94002 for the ventilator management and link it to 518.82 (Other pulmonary insufficiency, not elsewhere classified).

Tip: When you're coding for ventilation assist and management services, choosing ICD-9 codes is easy because you'll typically report one that indicates respiratory distress, according to says Jill Young, CPC-EDS, CPC-IM, of Young Medical Consulting in East Lansing, Mich. Respiratory failure and respiratory arrest, such as the following, commonly supports ventilation management services:

• 518.81 -- Acute respiratory failure
• 518.82 -- describes acute respiratory distress
• 518.83 -- Chronic respiratory failure
• 518.84 -- Acute and chronic respiratory failure
• 799.1 -- Respiratory arrest.

3. 94002-94003 Has Company

You will not always use 94002 or 94003 to report mechanical ventilation services.

Sometimes, your physician might also provide the patient continuous positive airway pressure (CPAP) ventilation or continuous negative pressure (CNP) ventilation to intermittently facilitate breathing. Sometimes you would report 94660 and 94662 based on the parameters of ventilation.

Example: The physician reports to the coronary care unit for a patient in acute respiratory distress who was admitted for congestive heart failure. After examining the patient, she decides to manage him with CPAP ventilation.

She documents her orders for management of the CPAP. CPT 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day) is not limited by the interfaces or modes utilized. You should report with 518.82 (Other pulmonary insufficiency not elsewhere classified) and 428.0 (Congestive heart failure unspecified).

A care provider can administer ventilator support through a variety of interfaces (such as, mouth piece or nasal, face, or helmet mask), using a variety of ventilatory modes (e.g., volume ventilation, pressure support, bilevel positive airway pressure [BiPAP], proportional-assist ventilation [PAV], continuous positive airway pressure [CPAP]). The patient can undergo either a noninvasive ventilation (NIV) or ventilation through an endotracheal tube or mask.

In the inpatient setting, the patient consistently requires ventilation support as opposed to the outpatient setting where the patient may only require assistance with sleep apnea. Alternatively, you would report 94660 for initiation and management of BiPAP (Other diseases of lung, not elsewhere classified) when the patient requires nightly assistance with obstructive sleep apnea.