Vent Management

nbohm

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I have a case with a patient 2 yrs old who had a repair of the transverse colon under general anesthesia. The patient remained sedated and intubated after the procedure and was transferred to ICU. In a separate note the CRNA has noted the transfer of care and with placement on vent.

The following morning I have detailed documentation at 630 of Vent Management including patient condition, review of systems and plans to extubate later in the morning.

The next CRNA note indicated at 945 the patient "passed extubation criteria sats 100%", details that pt was extubated and placement of a face mask with plans to continue to monitoring the patient.

How would we code this case? Would we be able to separately report placing the patient on the vent in ICU with the 94002 and then using 94003 for the following day? As the extubation is a separate encounter (time) would it be appropriate to bill with an E/M?

Thanks for any assistance.

Nikki
MO
 
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