Pulmonology Coding Alert

Whether you should use the ventilation management codes or the continuous positive airway pressure (CPAP) codes depends on the clinical intent and the patients underlying disease or medical necessity, according to Scott Manaker, MD, interim associate chair of clinical affairs and director of clinical documentation in the department of medicine at the University of Pennsylvania in Philadelphia. It isnt always a simple, straightforward decision, though, and sometimes an evaluation and management (E/M) code is the correct choice.

Fifteen years ago it was very simple, Manaker says. A patient in acute respiratory failure (518.81) was intubated and a mechanical ventilator was used to blow air. If respiratory failure was chronic (518.83), the physician used a positive-pressure ventilator. If the patient had obstructive sleep apnea (780.57), a CPAP machine was in order. Three clear clinical scenarios, three clear CPT Codes , and three clearly different ways of moving air for the patient:

94662 (continuous negative pressure ventilation [CNP], initiation and management)
94660 (continuous positive airway pressure ventilation [CPAP], initiation and management)
94656 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day) and 94657 (subsequent days)

Manaker says that many payers will reimburse ventilator management 94656 and 94657 only when the patient is in the hospital, not at home, because they view 94656 and 94657 as intended only for the acutely ill patient. For a chronically ill outpatient they want you to use code 94660, which means you are doing some type of home visit which most physicians dont do to manage that ventilator.

NIPPV vs. CPAP

Today, technology and creative medicine have eliminated the need for an invasive procedure for the patient with acute respiratory failure but have also made correct coding more difficult. Manaker says that in a postpayment review of a patient in acute respiratory failure who is being ventilated with a noninvasive positive pressure ventilator (NIPPV) machine, some insurers want to pay for only CPAP, not ventilation management. I would say thats wrong. It wont come up in a prepayment level, only in postpayment review, but certainly physicians worry about it. He says an NIPPV can be used appropriately for acute respiratory failure, chronic respiratory failure, vent management or obstructive sleep apnea.

If Im using a CPAP mask, but in conjunction with a mechanical ventilator for acute respiratory failure, and clearly the clinical intent is to provide full mechanical ventilatory support, it is correct and proper to use the vent-management code, Manaker says. He cites an example of a patient with chronic respiratory failure from [...]