Wiki Vent sedation in ED?

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monabuck

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Hello. My fellow auditors and I have gone back and forth about this one, so asking the AAPC cloud mind. If you have a patient who is intubated and sedated with propofol while in the ED, and then flown out to another hospital (patient is NEVER IP at this site), do you charge the propofol as an I&I? Or do you treat it as not billable, since it's fundamental to keeping the patient on the vent? I'm tending to say you wouldn't bill it, but probably wrong. Any ideas? What does your ED do for "fly out" patients? Thanks so much!
 
monabuck said:
Hello. My fellow auditors and I have gone back and forth about this one, so asking the AAPC cloud mind. If you have a patient who is intubated and sedated with propofol while in the ED, and then flown out to another hospital (patient is NEVER IP at this site), do you charge the propofol as an I&I? Or do you treat it as not billable, since it's fundamental to keeping the patient on the vent? I'm tending to say you wouldn't bill it, but probably wrong. Any ideas? What does your ED do for "fly out" patients? Thanks so much!
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I may be misunderstanding your question, and I'm not familiar with term 'I&I' that you're using. But assuming you are charging for the facility and not the professional services, I don't know why you wouldn't charge for the drug. The facilities I've worked with have always charged for all drugs and supplies used during any facility encounter, whether inpatient, outpatient or ED. Most are usually 'packaged' for payment by the payers into the case rates, and on inpatient claims will be rolled up into a single revenue code line, but that doesn't mean they shouldn't be charged. The claims need to reflect the facility costs, even if for payment purposes these aren't separately reimbursed.
 
thomas7331 said:
I may be misunderstanding your question, and I'm not familiar with term 'I&I' that you're using. But assuming you are charging for the facility and not the professional services, I don't know why you wouldn't charge for the drug. The facilities I've worked with have always charged for all drugs and supplies used during any facility encounter, whether inpatient, outpatient or ED. Most are usually 'packaged' for payment by the payers into the case rates, and on inpatient claims will be rolled up into a single revenue code line, but that doesn't mean they shouldn't be charged. The claims need to reflect the facility costs, even if for payment purposes these aren't separately reimbursed.
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Sorry, I've got a ton of stuff going on at the same time and I wasn't clear at all....It's facility charging, and the question is if we charge the administration code for the infusion (96365 and then 96366 for each additional hour). I went and double checked, they did charge the etomidate, roc and propofol. I know IP we don't charge it, but it's OP ED and since it's keeping the patient calm enough to tolerate being on the vent, to me, it would be part of the vent, and the drug administration not separately billable. But I may be completely wrong. I can't find anything that says "Thus sayeth the law" on this anywhere....
 
monabuck said:
Sorry, I've got a ton of stuff going on at the same time and I wasn't clear at all....It's facility charging, and the question is if we charge the administration code for the infusion (96365 and then 96366 for each additional hour). I went and double checked, they did charge the etomidate, roc and propofol. I know IP we don't charge it, but it's OP ED and since it's keeping the patient calm enough to tolerate being on the vent, to me, it would be part of the vent, and the drug administration not separately billable. But I may be completely wrong. I can't find anything that says "Thus sayeth the law" on this anywhere....
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OK, I see what you're asking. Yes, for inpatient you wouldn't charge the administration codes because those are considered inclusive in the room rates.

For outpatient services though, you should be able to tell by seeing if there is a facility CCI edit between the admin codes and the other codes you are charging on the same encounter. If there is, then you would only charge those admin services that would warrant a 59 modifier as being unrelated to the codes that consider the admin a bundled service. I don't think I've ever coded a situation with a vent on an outpatient claim - are you able to tell what codes are being billed for the management of the vent?
 
We didn't do initial vent management, because that's IP only here in this CDM. You can understand why half of us are saying "at least get the drug administration charge" and the other half are saying "it's included in the critical care minutes -- already charged." I wish I could find a definitive source to take back and show my group. I truly do appreciate your help.
 
monabuck said:
We didn't do initial vent management, because that's IP only here in this CDM. You can understand why half of us are saying "at least get the drug administration charge" and the other half are saying "it's included in the critical care minutes -- already charged." I wish I could find a definitive source to take back and show my group. I truly do appreciate your help.
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NCCI does have an edit between the critical care codes and drug administration codes on the physician side but not on the facility side, so if your facility is only billing the critical care time and no other codes specific to the vent, then it's appropriate to code the drug administrations as it's not considered a component of the facility's reporting of critical care time.

As a reference for you, look at Chapter 11 of the NCCI Manual which addresses critical care codes in section U. on E&M coding. Although it doesn't specifically mention drug administration, it does say that the services which may not be separately reported in addition to critical care when performed by professional providers (e.g. vent management, gastric intubation, interpretation EKGs and X-rays, etc.) may be separately reported by facilities, so there are actually fewer restrictions on the hospital side as to what is considered part of critical care than there are for practitioners.
 
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