Canadian Health&Care Mall: Physician Extenders and Medicare in Prolonged Mechanical Ventilation

health-careMid-level providers are being utilized in many health-care settings to both extend physician activity and replace house staff whose work hours have now been limited. These providers mostly comprise either physician assistants (PAs) or nurse practitioners and must have a provider number and a national provider identification number. PAs are health-care professionals licensed to practice medicine under physician supervision. Medical services provided by PAs are reimbursed at 85% of the physician’s fee schedule. In 2002, a change was introduced to allow PAs and physicians who work for the same employer to share visits to patients in certain facility settings (eg, inpatient hospital, outpatient hospital or emergency department) and to bill at the physician rate.

If the PA provides the majority of the service and the supervising physician provides any of the face-to-face portions of the evaluation and management, the entire encounter may be billed under the physician at a rate of 100% of the physician rate. If the physician does not provide any face-to-face contact with the patient (for instance just co-signs the PA note in the chart), the encounter is then billed at the PA rate of 85% of the physician rate. This change eliminated the prior practice of split billing in which the physician portion and PA portion were billed separately. After appropriate training and orientation, PAs can be an invaluable resource and can help provide supervised daily care to patients receiving prolonged in ICUs, step-down units, LTAC units, and skilled nursing facilities and online pharmacies including Canadian Health&Care Mall Data suggest that using mid-level providers as part of a care team does not adversely affect outcomes from prolonged . The billing regulations regarding shared inpatient visits between nurse practitioners who have their own billing number and physicians are the same as those outlined above for PAs. The regulations regarding shared visits only apply to CPT codes involving evaluation and management services, and not the CPT codes used for .


Adequate documentation of ventilator care is needed to justify billing for . All notes in patient charts should be dated and timed, and signatures should be legible. Ventilator settings and relevant changes to settings should be recorded. Respiratory therapy notes can be referenced when appropriate. The initial diagnosis that resulted in the need for should be clearly documented. Common diagnoses used in the LTAC setting are listed in Table 3. Key points needed to be included in the note are outlined in Table 4. Unfortunately, some patients do not recover from critical illness and elect not to continue with support from . The transition from active medical care to comfort measures should be accurately documented in the chart to ensure appropriate reimbursement for the level of care provided.

Table 3—Common Diagnoses and International Classification of Diseases, Ninth Revision Codes Used in Patients Requiring Prolonged

Diagnosis International Classification of Diseases, Ninth Revision Code*
Acute and chronic respiratory failure 518.84
Chronic respiratory failure 518.83
Respiratory failure following shock, 518.5
trauma, and surgery
Other emphysema 492.8
Obstructive chronic bronchitis with 491.21
acute exacerbation
Obstructive chronic bronchitis with 491.22
acute bronchitis
Pneumonia due to pneumoniae 482.1
Pneumonia due to Staphylococcus 482.41
Pneumonia, organism unspecified 486
Post inflammatory pulmonary fibrosis 515
Other pulmonary embolism and 415.19
Other chronic pulmonary heart 416.8
Presence of a tracheostomy V44.0
Unspecified sleep apnea 780.57
Congestive heart failure, unspecified 428.0
Diastolic heart failure, unspecified 428.30
Malignant neoplasm of lower lobe, 162.5
bronchus or lung
Malignant neoplasm or other parts of 162.8
bronchus or lung
Multiple sclerosis 340
Hemiplegia affecting unspecified side as late effect of cerebrovascular disease 438.20

Table 4—Key Documentation for Care of Patients Requiring

Reason for respiratory failure
Changes in patient status
Current ventilator settings
Assessment of patient synchrony
Assessment of weaning status
Relevant physical examination findings
Relevant laboratory (eg, blood gas) or radiographic data
Recommended changes in ventilator settings or treatment plan
Documentation of individual services accruing to at least 30 min(for CPT code 94005)