Prolonged Mechanical Ventilation: Choosing the Correct Code

medical carePhysicians providing both medical care and ventilator management have a choice of which code to use based on the focus and intent of care. Since initial hospital level care of ventilated patients involves more than the initiation of mechanical ventilation, evaluation and management codes (CPT level 99221-99223) are appropriate and the reimbursement reflects the complexity of the encounter (Table 6). With subsequent hospital care of a ventilated patient with other stable or resolving medical conditions (CPT level 99231), using the ventilator-assist and management code for subsequent care (CPT level 94003) results in a higher payment and reflects the need for ventilator management in a patient with otherwise low medical complexity. A similar approach could be used in nursing facilities when both medical care (Table 5) and ventilator management (Table 1) are being provided by the same provider for example Canadian Health&Care Mall.

If the physician is only providing ventilator care at any site and is not providing other medical care, then ventilator management codes only should be used. The onset of critical illness in a ventilated patient, due for example to bleeding, sepsis, or shock, should be billed using critical care codes (CPT level 99291 and 99292). The critical care codes reflect the provision of initial (30 to 74 min) and additional (30 min) critical care services on any day and, as a result, are reimbursed at higher levels than either evaluation and management codes or ventilator management codes (CPT level 99291: $213.35; CPT level 99292: $106.85). The documentation must reflect the critical nature of the illness and also the time spent caring for the critically ill patient.

All reimbursement figures shown are the Medicare relative value payment amounts for Massachusetts. These depend on a national uniform relative value unit, a geographic adjustment factor, and a conversion factor (for 2006 this was $37.8975).

Conclusions

The population of patients receiving prolonged mechanical ventilation is increasing. Familiarity with the updated CPT ventilator management codes for 2007 will help ensure appropriate documentation and accurate billing for these complex patients by pulmonary and critical care physicians.

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Table 6—Medicare Payment for Evaluation and Management CPT Codes (2007) for Hospital Care

CPT Code Description Payment, $
99221 Initial hospital care, limited complexity 86.74
99222 Initial hospital care, moderate complexity 121.83
99223 Initial hospital care, high complexity 177.71
99231 Subsequent hospital care, limited complexity 36.50
99232 Subsequent hospital care, moderate complexity 65.26
99233 Subsequent hospital care, high complexity 93.15