Association for Clinical Documentation Improvement Specialists

News: RACs target ventilator support

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July 21, 2011

RACs can easily data-mine for noncompliance related to coding for ventilator support, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, independent revenue cycle consultant in Madison, WI. For example, patients whose length of stay is fewer than two days can’t possibly be on a ventilator for 96 hours. "Simple math tells you this can't be correct," Krauss says. "Technically speaking, they almost don't even need to look at the record; they can tell by an automated review."

Coders should always refer to the respiratory flow sheet before coding any services related to ventilator support, he says. This flow sheet includes the intubation time, periodic dating and timing of ventilator management services, and the extubation time.

"If coders don't have the flow sheet, they absolutely need to track it down," Krauss emphasizes, adding that a hospital's coding compliance policy should explicitly mandate this.

Coders shouldn't rely entirely on physician orders of intubation and extubation times, agrees Alice Zentner, RHIA, director of auditing and education at TrustHCS in Springfield, MO. "Coders need to go by the actual documentation. They need to have solid documentation of the times," she says.

However, even when documentation exists, counting the number of ventilator hours can sometimes be confusing. Coding Clinic has yet to provide guidance regarding what to do in scenarios where a patient doesn't receive a full hour of ventilator support, says Zentner. For example, should coders report an additional hour of ventilation when the patient receives only 25 minutes? Without definitive guidance, Zentner cautions against it.

Here are a few pointers on what can count when calculating ventilator hours:

The number of hours the patient spends on a mechanical ventilator while he or she is in observation or in the ER prior to admission. See Coding Clinic, Second Quarter 1992, pp. 13–14.
The number of hours spent weaning the patient off the mechanical ventilator.
The number of hours the patient receives continuous invasive mechanical ventilation, such as continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP), when delivered through an endotracheal tube or tracheostomy. See Coding Clinic, Fourth Quarter 2008, p. 187.

Here's what coders can't include when counting ventilator hours and what RACs may look for when trying to identify overpayments:

The number of hours the patient spends on the mechanical ventilator before he or she arrives at the hospital. See Coding Clinic, Third Quarter 2010, p. 3.
The number of hours the patient receives noninvasive mechanical ventilation (e.g., CPAP and BiPAP) not delivered via an endotracheal tube or tracheostomy. See Coding Clinic, Fourth Quarter 2008, p. 187.
The number of hours the patient receives manual ventilation, such as when an emergency medical technician performs manual bagging while the patient is in the ER. Ventilation time starts when the patient is placed on a mechanical ventilator. See Coding Clinic, Second Quarter 2003, p. 17.

CDI specialists need to be aware of the expectations and limitations of what coders can and cannot use and help to obtain clarity for such situations when warranted.

Editor’s Note: This article first appeared in the July issue of Briefings on Coding Compliance Strategies.

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