ED Coding and Reimbursement Alert

But your emergency physician will rarely provide just ventilator management.

If your physician provides initial-day ventilation management services in the course of treating a critically ill or injured patient, be sure you choose the critical care code instead of a ventilation management code or you may not be following the CPT^® guidance. When your emergency physician provides ventilation management, it is usually for a patient requiring high-level ED E/M service, subsequent hospital care, or typically in most cases, even critical care. 

The reason: Ventilation management, when performed, is bundled into the critical care code (and most other E/M codes); these E/M codes are a more accurate representation of the high complexity multi-faceted evaluation and patient management that is being provided, says Michael Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company in Bedford, MA.

"It should be noted that code 94002 may not be reported in conjunction with evaluation and management services 99201-99499," according to the March 2007 CPT^® Assistant^®.

The 2017 CPT^® parenthetical which follows the code descriptor also backs this up: "Do not report 94002-94004 in conjunction with E/M services 99201-99499."

Additionally, ventilation management codes are bundled into most E/M codes, including critical care, Granovsky adds.

Without Sufficient E/M Documentation, You Can't Use 94002-94003

The 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) CPT^® codes are used mostly by pulmonologists, though it is possible the emergency physician will provide these services in certain isolated instances.

Consider Reporting an E/M, if the Physician Goes Beyond 94002, 94003

If the notes indicate that the ED physician provided ventilation management in the course of a greater E/M service, you'll want to be sure to bundle all of the encounter work and choose the proper E/M code, Granovsky says.

Here's why: With few exceptions, the physician will provide a high-level ED E/M service (such as 99284, 99285 or 99291), which is a more appropriate representation of the additional cognitive work being performed beyond simply managing the ventilator settings.

The national unadjusted payment rates for ventilator management are as follows: for 94002 - $94.75 (2.64 facility relative value units [RVUs] multiplied by the 2017 Medicare conversion factor of 35.8887), while 94003 reimburses an average of $68.19 (1.90 RVUs times 33.8887).

Example: At 4 am, an emergency physician is called by the critical care unit to see a patient with congestive heart failure who has suffered acute respiratory failure and had been placed on a ventilator two hours earlier. The emergency physician performs a history and physical exam; and reviews lab work, blood gases, ongoing laboratory studies and consultants' notesand recommendations for ongoing treatment. The emergency physician documents ventilator settings and, based on the recent blood gases, makes an adjustment to the ventilator settings, along with the data necessary to provide the initial day of ventilator care; notes indicate 12 minutes of ventilator management.

In order to further stabilize this critically ill patient, the physician spends another 48 minutes providing critical care services including adjusting several intravenous vaso-active medications and changing the patient's antibiotics.

Since the physician provided critical care for the patient, you would add up total session minutes (48 + 12 = 60) and report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the physician's services.

Critical Care is a better representation of the physician's cognitive effort. In this case the highly complex bedside work involved reviewing significant data for a critically ill patient and adjusting the ventilator setting. The more appropriate code choice is 99291.

Nationally unadjusted payment rates for 99291 are as follows:

$226.82 (6.32 facility relative value units [RVUs] multiplied by the 2017 Medicare conversion factor of 35.8887), says Granovsky says.