Health Information Management

Q&A: Why can’t we bill ventilator management in the ED?

APCs Insider, May 23, 2014

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Q: An auditor recently reviewed our outpatient ED claims and told us that we cannot report CPT® code 94002 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day) when we establish a ventilator in the ED. We have a lot of resources involved in this service and think the auditor is wrong. Do you have any insight?
A: There are a couple of reasons that this code should not be reported for an outpatient in the ED. First, CPT code 94002 is specifically defined as representing services for an inpatient or observation services patient. If the patient is an outpatient—that is, there is no order and documented medical necessity for observation services or inpatient admission—then this code is not reportable.
The second reason is that the National Correct Coding Initiative (NCCI) Manual specifically states that CPT 94002 cannot be reported separately with an E/M service. The ED visit codes (CPT codes 99281-99285) are E/M codes. When a visit code is reported, the ventilator management codes cannot be reported separately. The manual states in Chapter 11:
Pursuant to the Federal Register (Volume 58, Number 230, 12/2/1993, pages 63640-63641), ventilation management CPT codes (94002-94004 and 94660-94662) are not separately reportable with evaluation and management (E&M) CPT codes. If an E&M code and a ventilation management code are reported, only the E&M code is payable.
However, I have good news! You can capture the resources for the ventilator management service in the ED visit level that you report. This will capture the resources and report them to CMS and other payers, but still allow you to submit a correctly coded claim.
Reporting the ventilation management codes on the same claim as an E/M service (including ED level) will cause the Comprehensive Error Rate Testing (CERT) program to consider this an incorrect claim. Also, check your remittance advices to ensure that the MACs are not reimbursing for the ventilator management service on the same claim as the ED level. If they are making a separate payment, this will cause a reversal of revenue upon federal audit.
Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.

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