Pulmonology Coding Alert

Tip: Present providers with better-paying codes.

All the mix and match of coding ventilator management could add to the complexity of appropriately reporting and reimbursing your claims. Let our experts guide you through how to post your claims with accuracy.

Note: Medicare contractors implement coding edits in their electronic claims logic, and if you bill the ventilator management code along with an E/M code, Medicare will deny the claim or pay the lesser valued service. Getting paid for both a ventilator management code and an E/M code doesn't occur with Medicare or other payers.

Make Up Your Mind: Ventilator Management Code or E/M

Scenario 1: Your pulmonologist provides ventilator management. The progress notes describe the service as more in line with 99291. But you think 94003 is a better choice.

Solution 1: Let the encounter notes lead you to the appropriate code, but you should also consider the relative value units (RVUs) since this reflects the amount of physician effort  required. The physician work RVU for 94003 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day) is 1.37 -- which is about $50, while the RVUs for 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30 -74 minutes) is 4.50 -- which pays about $162.

"Recognizing that critical care is highly valued, it also requires a lot more physician work and corresponding documentation. If the service is appropriately documented as critical care, don't undervalue it by reporting ventilator management," Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia advises.

For example, if the patient has acute respiratory failure, which the pulmonologist manages, along with other underlying conditions, critical care codes may be more appropriate. Besure you document critical care time before using the critical care codes. If no time documentation is present, consider 99232 or 99233 as a more appropriate E/M to use.

Don't forget: Payers bundle all ventilator management codes (94002-94004, 94660, 94662) into E/M codes, meaning you cannot report ventilator management with an E/M service. When your pulmonologist provides ventilator management, you'll have to decide whether to report the ventilator management code or roll that work into an E/M code, says Kent Moore, a healthcare financing and delivery systems manager in Leawood, Kan.

Make good use of your pulmonologist's notes for encounters,which should lead you to the proper code choice.

Rule of thumb: If the pulmonologist focuses on ventilation management during the encounter and does not document key components warranting an E/M, report a ventilation management code. But if the notes describe an encounter in which the physician performs ventilation management in addition to providing care for the patient's other problems, report the E/M code if the documentation will support that choice.

Don't Disregard Patient Status

Scenario 2: A hospital inpatient experiences acute respiratory failure, is intubated, and needs ventilator assistance to breathe. The pulmonologist evaluates the patient, and directs both the ventilator setup and the patient's first-day ventilator management.

Solution 2: Report 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day) for ventilator management. Report the patient's condition by appending 518.81 (Acute respiratory failure) to 94002.

If your pulmonologist treats a patient exclusively for ventilator management, you'll choose from 94002, 94003, or 94004 (... nursing facility, per day) depending on the location of the service and the day of treatment, says Denae Merrill, CPC, coder for Covenant MSO in Saginaw, Mich.

Important: Code 94002 includes the pulmonologist providing the service, reviewing the patient's chart, seeing the patient, writing notes and communicating with other healthcare professionals and the patient's family/caregiver, Merrill adds.

Ventilation Doesn't Always Mean Invasive

Scenario 3: A 67-year-old patient with obstructive chronic bronchitis and emphysema is seen in the hospital for increasing PaCO2 levels in spite of therapy.

The pulmonologist orders nocturnal BiPAP (bilevel positive airway pressure) to treat the patient. In this instance, the ICD-9 codes would be 491.21 (Obstructive chronic bronchitis -- with exacerbation) for the obstructive chronic bronchitis and emphysema with an acute exacerbation.

Solution 3: You should report 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management).

Pulmonologists don't always recommend invasive mechanical ventilation as typically identified with codes 94002-94004. She may opt for continuous positive airway pressure (CPAP) ventilation, bilevel (BiPAP) ventilation, or continuous negative pressure (CNP) ventilation to facilitate breathing. Patients may receive CPAP via mask or endotracheal tube, with or without a ventilator. When your pulmonologist requires CPAP for intermittent assistance in sleep-related disorders, or conditions that do not require continuous ventilatory support (i.e., sleep apnea), report 94660.

Report 94660 for the initiation of CPAP or BiPAP, and 94662 (Continuous negative pressure ventilation [CNP], initiation and management) for the initiation of CNP.

Reminder: When the pulmonologist uses CPAP or BiPAP to ventilate patients with acute respiratory conditions, such as acute respiratory distress, she may elect to report 94002-94004 for the continuous invasive ventilation. Documentation should be clear about the mechanism used, the patient's diagnoses (i.e., the reason for the ventilation), the duration of treatment, and the patient's response to treatment.

Chronic Cases Call for CNP

Pulmonologists use CNP when they want patients to receive nigh-time respiratory muscle rest with negative pressure ventilation.

Example: A pulmonologist examines a hospital inpatient diagnosed with Guillain-Barre disease who is recovering, but has chronic respiratory failure. The pulmonologist orders ventilatory assistance at night via a Cuirass ventilator,recommends the ventilator settings for CNP, and evaluates the patient's breathing while on the ventilator.

Go for 94662 on the claim. Make sure you include the ICD-9 code 518.83 (Chronic respiratory failure) to document the patient's chronic respiratory failure and 357.0 (Acute infective polyneuritis) to describe the patient's Guillain-Barre disease.