ED Coding and Reimbursement Alert

Patient's status, therapy type lock down pay If you report ventilation therapy when your ED physician performed critical care, you could lose out on over $100 per claim. But breathe easy: If you focus on the encounter notes, you-ll know when to choose a ventilation assist code and when to opt for the E/M. Patients who require ventilation assist and management present a unique coding challenge. The ED physician might provide the ventilation assist only, or he might provide ventilation services during the course of a high-paying E/M service, such as critical care. Choose Either Vent Therapy or E/M According to CPT, all of the ventilation therapy codes mentioned in this article (94002, 94003, 94660, 94662) are bundled into E/M codes. Therefore, you cannot report ventilation therapy with an E/M service. Impact: When your ED physician performs 94002, 94003, 94660 or 94662, you-ll need to decide whether to report the ventilation therapy or roll the work into the E/M level, says Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California. Notes for these encounters will likely lead you to the proper code choice: 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. Benefit: Choosing to report the E/M instead of ventilation management, when allowable, may benefit the practice's bottom line. The E/M codes typically associated with ventilation management services require much more work and documentation -- and pay at a higher rate -- than the ventilation management codes. "In most cases, if you did enough work to qualify for an E/M level, you would want to report the E/M," says Denae Merrill, CPC, coder for Covenant MSO in Saginaw, Mich. Example: If you choose to report 94003 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day), but your physician provides services more in line with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), you will miss out on approximately $118 in work values. The physician work relative value units (RVUs) reimbursement for 94003 is about $52 (1.37 RVUs), while 99291 pays about $170 (4.50 RVUs). (Note: For more information on identifying critical care services, see "Prove Patient's Critical State Before Coding 99291" on page 19.) Check Patient Status Before Coding Management Of course, you-ll also encounter situations in which the best coding option is a ventilation management code. If [...]