*From the Department of Pulmonary and Sleep Medicine, New England Sinai Hospital, Stoughton, MA.
Correspondence to: Alexander C. White, MD, MS, FCCP, Department of Pulmonary and Sleep Medicine, New England Sinai Hospital, 150 York St, Stoughton, MA 02072; e-mail: firstname.lastname@example.org
The goal of this article is to provide an update on recent changes to current procedural terminology codes used for billing physician services for mechanical ventilation in chronic care facilities. In addition to billing information, background data relevant to prolonged mechanical ventilation are reviewed. Topics covered include a description of the settings in which patients receive prolonged mechanical ventilation; home mechanical ventilation; the role of physician extenders; documentation of ventilator services; and reporting and coding ventilator management.
The American Medical Association has published new and revised ventilator management codes for 2007 that were implemented on January 1, 2007 (Table 1
). This article addresses clinical and billing issues pertinent to this topic.
The numbers of patients requiring prolonged mechanical ventilation appears to be increasing. This trend likely reflects improved ICU survival, a trend toward earlier tracheostomy, and pressure to reduce length of stay at some acute care facilities. Current data indicate that 5 to 20% of subjects receiving mechanical ventilation in the ICU will require prolonged mechanical ventilation.1–3
A recent consensus conference has recommended that prolonged mechanical ventilation be defined as the need for continual assistance from a mechanical ventilator for at least 6 h/d for at least 21 days.1 As yet, this consensus definition has not been uniformly accepted or implemented but appears to be a useful way of defining prolonged mechanical ventilation. Patients who require prolonged mechanical ventilation usually have a tracheostomy tube placed when they are still in the ICU. Epidemiologic data indicate that the number of patients undergoing tracheostomy for prolonged mechanical ventilation is increasing.4Outcome data indicate a trend toward earlier placement of a tracheostomy tube in the course of critical illness.5 Patients who require prolonged mechanical ventilation via tracheostomy are considered chronically critically ill. The exact point in time when the transition from acute to chronic critical illness occurs has been difficult to determine. Any definition would need to encompass time dependent on mechanical ventilation, time of onset of hemodynamic and pulmonary stability, and the availability of a bed outside of the ICU setting to care for the patient.
Patients requiring prolonged mechanical ventilation in the United States receive their care in a number of different settings. In some states, patients stay in the ICU for a prolonged period of time because other sites of care do not exist in the surrounding area. This trend has resulted in some hospitals creating respiratory acute care units (also known as intermediate care units or step-down units). These units, located within an acute care facility, allow hemodynamically stable patients who require prolonged mechanical ventilation to be moved from the ICU to a unit within the acute facility. Patients can be easily transferred back to the ICU if they require critical care. Respiratory acute care units in acute care facilities help improve the efficient use of ICU beds and prevent disruptions in the flow of critically ill patients between operating rooms, emergency departments, and ICUs (B.R. Brown, MD; personal communication; March 2007). Care given to patients in a respiratory acute care unit is reimbursed by Medicare according to the inpatient prospective payment system (physicians, who may or may not be employed by the health-care facility, may obtain reimbursement for their professional services through Part B for Medicare beneficiaries). The cost of caring for patients requiring a prolonged hospital stay in the acute care facility has been reported to be a problem because the duration of hospitalization may be in excess of the diagnosis-related group-assigned length of stay.6–7
Long-term acute care (LTAC) hospitals are acute hospitals with an average length of stay of 25 days.6 Due to the high cost of caring for mechanically ventilated, medically complex patients, the Medicare base rate of reimbursement per discharge is significantly higher in LTAC facilities as compared with that provided to acute care facilities ($38,086 vs $5, 308).6 LTAC hospitals can be either freestanding or located as a unit within a hospital, usually an acute care facility, and provide service intensity like an acute care facility with clinical and ancillary support services available on site.8 The practice of co-locating an LTAC unit within an acute facility may be diminishing in response to recent changes in Medicare policies regarding referrals from the co-located acute facility.6
Historically, some free-standing LTAC hospitals evolved from tuberculosis hospitals. As the prevalence of active tuberculosis declined with effective chemotherapy, other patient populations were cared for in this setting, included those with neuromuscular disease or cervical spine injuries. These patients required prolonged mechanical ventilation and required lifetime placement because they were unable to live independently. In some states, such as Massachusetts, small numbers of these patients remain long-term residents in some LTAC hospitals.
The numbers of LTAC hospitals significantly increased in the 1990s, particularly in Texas, Louisiana, Ohio, Pennsylvania, and Michigan, due in part to a favorable reimbursement environment as outlined above. As a result, the majority of LTAC facilities are located in states that have a large Medicare population.6 The need to reduce the length of stay in acute care facilities increased the flow of patients with chronic, critical illness or complex medical illness to LTAC hospitals, changing the patient population once again. Currently, 9.3% of patients at 50% of LTAC hospitals are those requiring mechanical ventilation.6 Patients receiving mechanical ventilation admitted to LTAC hospitals for continued acute care have a pulmonary diagnosis that necessitates mechanical ventilation and may have a high degree of medical complexity.9 The prolonged length of stay at the LTAC hospital allows for extensive rehabilitation to occur at the same time as the medical issues are being treated, thus optimizing the chances of functional recovery for patients with prolonged critical illness.
Free-standing rehabilitation facilities also provide care for some patients who require prolonged mechanical ventilation. Two reports10–11 indicate that patients cared for in this setting include those with neuromuscular disease, spinal cord injury, thoracic wall restriction, and COPD. The use of noninvasive ventilation or diaphragm pacing12 can allow some patients with low spinal cord injury and restrictive disorders of the thoracic wall to be decannulated. A significant percentage of these patients may be able to return to living in the community.11 In one study,13 insurance status was an independent predictor of discharge to a rehabilitation center from a trauma center. The Medicare base rate per discharge in 2007 was $12, 952 and is adjusted for functional impairment levels and complicating comorbidities. This base rate precludes rehabilitation facilities caring for patients receiving mechanical ventilation who are medically complex.
The prevalence of mechanical ventilation in skilled nursing facilities in the United States is difficult to estimate. A MEDLINE search combining the terms “nursing home” and “mechanical ventilation” yielded five relevant articles published from 1997 to 2007. Review of these articles indicates that patients in some states (eg, Maryland) do undergo mechanical ventilation in skilled nursing facilities,14but comprehensive epidemiologic data are difficult to find. There are approximately 50 nursing homes in New York State that offer ventilator services.15 Weaning protocols along with noninvasive mechanical ventilation as a bridge to decannulation have been used successfully in the nursing home setting.14,16Other relevant issues reported in the skilled nursing facility setting include management of ventilator-associated pneumonia,17the choice of provider overseeing mechanical ventilation in the nursing home, and the need for advanced directives in this population.18
The availability of a unit that can provide care for patients requiring prolonged mechanical ventilation determines if a patient is able to move out of the ICU setting into an environment that favors rehabilitation as the acute medical issues resolve. Outcome data obtained in the LTAC hospital setting indicate that up to 54% of subjects undergoing prolonged mechanical ventilation may eventually be freed from the ventilator.3 Attempts have been made to develop prediction tools to help guide short-term and long-term mechanical ventilation decisions in this population, but these tools need validation in larger studies.19
A small percentage of patients receiving prolonged mechanical ventilation can be safely discharged home on a mechanical ventilator with extensive family or other caregiver support.6 The majority of the literature on home mechanical ventilation has been generated outside of the United States.20–22 Patients with amyotrophic lateral sclerosis,23Duchene muscular dystrophy, kyphoscoliosis-related respiratory failure,24postpoliomyelitis syndrome-related respiratory failure,25and obesity hypoventilation syndrome26make up a significant percentage of those receiving home mechanical ventilation. A multidisciplinary team of motivated caregivers is essential to provide optimal home care for these vulnerable patient populations requiring home mechanical ventilation. Meticulous discharge planning is required to transition the patient requiring long-term mechanical ventilation to home.27 Follow-up after discharge can be difficult to coordinate because transportation to and from an outpatient clinic can present logistical problems for patients and their caregivers. A home visit (current procedural terminology [CPT] codes 99341-99350, Table 2
) by a pulmonary physician, if feasible, can be useful to help optimize home mechanical ventilation. Prior to discharge, the community pulmonary physician should receive an educational session on how the home ventilator functions because the user interface of these units may differ significantly from the interface seen in ICUs based mechanical ventilators.,20 As a general guideline, the pulmonary physician needs to work with a respiratory care company providing home care (and occasionally a visiting nurse organization) to review ventilator settings on at least a monthly basis to ensure the prescribed ventilator settings match the actual settings on the home ventilator.22 Monthly review of ventilator settings can be reported using CPT level 94005 (Table 1).
Mid-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.28These 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.29Medical 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.30 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 mechanical ventilation in ICUs, step-down units, LTAC units, and skilled nursing facilities. Data suggest that using mid-level providers as part of a care team does not adversely affect outcomes from prolonged mechanical ventilation.31The 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.32 The regulations regarding shared visits only apply to CPT codes involving evaluation and management services, and not the CPT codes used for ventilator management.
Adequate documentation of ventilator care is needed to justify billing for ventilator management. 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 mechanical ventilation should be clearly documented. Common diagnoses used in the LTAC setting are listed in Table 3
. Key points needed to be included in the ventilator management note are outlined in Table 4
. Unfortunately, some patients do not recover from critical illness and elect not to continue with support from mechanical ventilation. 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.
There are four new CPT codes available for reporting ventilator management, and these are summarized in Table 1. Three of the codes, 94002, 94003, and 94004, cannot be used in conjunction with evaluation and management codes 99201-99499. A face-to-face encounter between the reporting physician and the patient is required to report ventilator management.
This code is used when a patient is initiated on mechanical ventilation for respiratory failure as an inpatient or under observation status in a hospital (including an LTAC hospital). Documentation for this code would include the reason for initiation of mechanical ventilation, the selection of settings of the ventilator (mode of mechanical ventilation; tidal volume; pressure settings; peak flow rate; inspired oxygen concentration and level of positive end expiratory pressure), and any adjustments needed to minimize patient/ventilator dysynchrony. Evaluation and management codes cannot be billed for the patient on the same day by the same provider when this code is used.
This code is used for subsequent daily ventilator care. Documentation used to justify this code would include recording the ventilator settings, a physician evaluation of patient/ventilator synchrony, and any adjustments made to the patient/ventilator interface to enhance synchrony and facilitate weaning. Evaluation and management codes cannot be billed for the patient on the same day by the same provider when this code is used. For CPT codes 94002 and 94003, the place of service codes 21 (inpatient hospital or LTAC hospital) or 61 (comprehensive inpatient rehabilitation facility) should be used.
This is a new code designed for use when ventilator management (either initiation or subsequent ventilator care) is performed on a patient in a skilled nursing facility. This code can be used by a pulmonary physician providing ventilator management to a patient receiving nursing facility care (CPT codes 99304-99310; Table 5
) from a different physician. For example, patients may require weekly or less frequent ventilator care management if stable and more frequent ventilator care during weaning attempts or intercurrent illness. Documentation would include the reason for the mechanical ventilator, a comment on patient/ventilator synchrony, results of weaning attempts, and current ventilator settings as detailed in Table 4. For CPT code 94004, the place of service code would be 31 (skilled nursing facility) or 32 (nursing facility).
This is a new code to be used when patients receiving mechanical ventilation are managed at home or in a domiciliary setting (eg, an assisted-living facility). There need not be face-to-face contact with the patient to bill for this service. It requires a ≥ 30 min review of pulmonary status, laboratory results, revision of visiting nurses orders, and review of reports from home respiratory care providers. Documentation must indicate how the provider spent 30 min reviewing the patient’s status (eg, time log for record review or telephone conversations) and must be provided by the provider and not by a home care company. Payors, including Medicare, may “bundle” these services and therefore may not reimburse for them. These reports are usually faxed or mailed to a doctor’s office for review, and the ventilator settings reviewed by telephone with the patient, caregivers, visiting nurse association, and home care company. This can be billed once a calendar month and can be billed even when a different physician may be billing CPT codes 99339-99340. Practitioners caring for patients receiving mechanical ventilators at home are encouraged to use this code. The point of service code for home services is 12.
This code is used to report the use of either continuous positive airway pressure or bilevel positive airway pressure in a patient with respiratory failure who does not need continuous mechanical ventilation. This code has not changed. Providers may not bill an evaluation and management code in addition to CPT code 94660 for the same patient service.
This code has not been changed and is used to report the use of continuous negative pressure ventilation in patients with respiratory failure. This type of mechanical ventilation is not commonly used.
Physicians 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. 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).33–34
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.
Abbreviations: CPT = current procedural terminology; LTAC = long-term acute care; PA = physician assistant
The authors have no conflicts of interest to disclose.
From the American Medical Association.33
Amount reimbursed may vary with locality and type of facility.
These codes may not reflect covered indications required for payment by insurer.
We would like to acknowledge Susan Marre, Sarah McGillowey, Lawrence Hotes, MD, and Brian Bloom, MD, for invaluable help in synthesizing the article. We also thank Caroline Peucker of Hart Associates for advice.
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