ED Coding and Reimbursement Alert

While it's true that the ED is ground zero for "anything can happen," ED coders will have few opportunities to report ventilation management codes -- but that does not mean your physician won't provide ventilation management services.

Explanation: There's usually a better coding course of action to accurately capture your physician's services -- namely, choosing an E/M code over a 9400x code. Check out this advice on best practice for coding your ED physician's ventilation management services.

The two ventilation management services your ED physician could theoretically provide are represented by 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation; initial day) and 94003 (... hospital inpatient/observation, each subsequent day).

Though any physician can report these codes, they are mostly used by pulmonologists, explains Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

These ventilation management codes "are more intended to be used by a pulmonologist that is managing the patient for the whole 24-hour period," confirms Sharon Richardson, RN, compliance officer with Emergency Groups' Office in Arcadia, Calif.

Further, both of these codes are bundled into all E/M codes (99201-99499), so you cannot carve out the 94002 service and also code an E/M, for instance. The only time you'd consider reporting 94002 or 94003 in the ED is when the entire encounter centers on ventilation assistance and no other area of evaluation or management is addressed.

Otherwise, you're better off with an E/M code based on the encounter notes, experts agree.

Not only is it typically more accurate to report an E/M code when your ED physician performs ventilation management, it is also usually higher-paying.

"I haven't seen a chart where the MD provided vent management without also performing an E/M -- and if a patient is on a vent and requires ED physician intervention, the E/M service will most likely be of fairly high-complexity," relays Richardson.

Example: A vent-dependent wheelchair-bound patient with advanced MS is brought to the ED for evaluation of increased respiratory rate and concern about the vent settings following a visit from a new home care nurse. The ED physician checks a blood gas and chest x-ray, which confirm there is a problem and reviews the patient's old record to check the prior vent settings. The physician concludes that the patient's vent rate was accidentally set too low. He orders a change to the ventilator's rate and the patient improves, becoming more comfortable.

In this instance, the ED physician provided 94002 service during a 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) encounter, so you'd roll the ventilation management work into your overall E/M level.

Pay difference: The 94002 code pays about $87 (2.43 transitioned facility relative value units [RVUs] multiplied by the 2009 Medicare conversion rate of 36.0666), while 99285 pays around $170 (4.72 RVUs multiplied by 36.0666).