Pulmonology Coding Alert

As every pulmonologist is acutely aware, the coronavirus emergency has prompted a ventilator shortage at some hospitals so severe that the US Public Health Service issued a directive on March 31 called “Optimizing Ventilator Use During the COVID-19 Pandemic.” As physicians work to intubate patients, it’s become clear that some coders are struggling to keep up with the claims.

Many of the recent questions coming into Pulmonology Coding Alert involve vent management, so we’ve rounded up some best practices that will keep your vent management claims error-free.

1. Location, Time Drive Vent Management Code

When your pulmonologist uses ventilation management to treat respiratory failure, you should choose from the following codes:

• 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/ observation, initial day)
• 94003 (... hospital inpatient/observation, each subsequent day)
• 94004 (...nursing facility, per day)

Tip: You should know the location of where the vent management was performed, as well as the day (initial or subsequent) for some locations, to select the appropriate code, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Scrutinize Documentation

During each vent management visit, the pulmonologist should record the ventilator settings and adjustments. This includes the initial or current vent settings, any changes to those, and recommendations and/or orders relating to the vent setting changes.

Once you know how your pulmonologist administered the ventilation, look at when they administered the treatment. Choose the correct code based on whether you’re reporting the first day of ventilation or subsequent days.

Example: A hospitalist calls your pulmonologist into the intensive care unit to set up the patient, who has just been intubated, on a ventilator. The patient has been diagnosed with COVID-19 and is in acute respiratory failure. The pulmonologist examines the patient, reviews the pertinent data including chest X-rays, and orders the ventilator settings. He then writes a note describing what he’s done, documenting all the ventilator settings and how to monitor the patient including measuring arterial blood gases.

You should report 94002 for the first day of the ventilation and 94003 for subsequent days. Link the visit to U07.1 (COVID-19) as your primary diagnosis and J96.00 (Acute respiratory failure, unspecified whether with hypoxia or hypercapnia), or a more specific diagnosis as the secondary diagnosis.

2. Differentiate Vent Management From CPAP

Although most vent management in the acute care setting (and particularly during the COVID-19 pandemic) takes place on a ventilator, keep in mind that some documentation referring to “vent management” sometimes actually takes place using a continuous positive airway pressure (CPAP) machine.

If the pulmonologist initiates CPAP on an intubated patient, you should select 94660 (Continuous positive airway pressure ventilation (CPAP), initiation and management). But if the physician initiates negative pressure ventilation, you should use 94662 (Continuous negative pressure ventilation (CNP), initiation and management). The most frequent use for 94660 is in the outpatient setting for the patient with sleep apnea on whom the pulmonologist initiates nasal CPAP to use during sleep. This is a starkly different service from acute care vent management, so be sure never to confuse these codes.

3. Choose Between E/M and Vent Management

If your pulmonologist performs ventilator management and an E/M, you’ll have to look at the documentation to see which you should report. Because of National Correct Coding Initiative (NCCI) edits, you can never bill ventilator management with an E/M code, such as 99221 (Initial hospital care...) or 99291 (Critical care ...).

The bottom line: Base your coding on the level of assessment and decision making your pulmonologist documents. Choose either the E/M or the ventilation management depending on the medical record. If your pulmonologist’s service focuses on vent management, and they did not document all the necessary elements in the key components warranting an E/M service, you should report a vent management code.

If, however, your physician performs and documents the necessary items of the key components, expanding beyond issues merely related to the ventilation, select an E/M code.

Remember: Subsequent-day ventilation management pays less than subsequent hospital care (levels 2 and 3). It is up to you and your pulmonologist which code you report, but the documentation must support the selected code and the medical necessity of the service.