Pulmonology Coding Alert

The key here is in the definition of 94656, specifically the phrase "initiation of pressure or volume preset ventilators," says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Sometimes a patient will use a mask hooked to a CPAP machine at home for certain conditions, such as sleep apnea. CPAP initiated by this method would be reported as 94660.

But suppose the pulmonologist decides to use a noninvasive method to assist an elderly emphysema patient suffering from acute respiratory failure. He hooks a mask onto a mechanical ventilator in the MICU. The appropriate code would be 94656 in this case. According to Laura Boyette, Anchor Health Centers in Naples, Fla., you should code the first initiation with 94656 and any subsequent ventilation management even by other doctors with 94657.

If the pulmonary physician intubates the patient, you can report 31500 (Intubation, endotracheal, emergency procedure) in addition to the ventilation code. Occasionally, he may perform a tracheostomy to ensure a safe airway, and you may report this service separately as 31600 (Tracheostomy, planned [separate procedure]).

Question 3: The pulmonologist visits a patient undergoing acute respiratory failure in the MICU. During the visit, he initiates and adjusts mechanical ventilation for the patient. Should you report 94656, or an appropriate hospital care code (99221-99233)? 
First, remember that you can never bill ventilator management with an E/M code, says Darcy Crabb, patient account representative, Pulmonary Associates, in Sioux City, Iowa. She says you have to choose between billing for the E/M or ventilation management and asserts that she most often chooses to bill for an E/M.

Your decision should depend on the extent of the pulmonologist's activities during the visit and the available documentation. If he simply initiates ventilation and notes this activity, you should only report 94656. However, say the physician fulfills the requirements of documenting history, examination and decision-making. You can then report the appropriate level of hospital care (99221-99233).

Question 4: Given the same scenario, when can you report critical care services for the pulmonologist's visit?
Do not make the mistake of reporting critical care services simply because the patient is on a ventilator or in the MICU. The patient must meet CPT and CMS requirements for critical care. You can find these in the CPT manual and at the CMS Web site, www.cms.gov.

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 for the first 30 to 74 minutes, and 99292 for each additional 30 minutes.

When the patient is critical but the time spent with the patient is less than 30 minutes, you should report a hospital inpatient service (99221-99233) or ventilation management (94656-94657). 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, Crabb says. Since you cannot bill for both on the same day, she recommends billing 99291, assuming all criteria are met for critical care services.

When you report critical care codes, do not also bill for ventilation management. CPT includes 94656-94657 in the critical care codes, Boyette says. She says her practice bills for ventilation management when the doctor only checks the ventilation, which rarely happens. Time spent with ventilation management can be counted toward critical care because you are not billing separately for the service.

Question 5: The pulmonologist sees an inpatient at 10:00 for an E/M visit. Later that day, the patient undergoes respiratory failure and is transferred to the MICU. Can you report the E/M visit and 94656 on the same day?
Since CPT and CCI bundle ventilation management into the E/M services, you cannot report these two services on the same day. CCI does not allow this edit to be overridden despite the fact that these services were provided at separate instances during the day. Your best bet is to report the appropriate E/M code, because reimbursement for E/M services is usually higher.

Question 6: What documentation will support medical necessity for 94656?
You include documentation for ventilation management in the patient's chart. Boyette says her pulmonary physicians do not dictate separate notes. They simply document ventilation settings in the progress notes. Also, include detailed notes on the patient's condition and diagnosis.