Question:

How is a hospital paid for mechanical ventilation provided for inpatients?

Answer:

The MS-DRG payment is, with certain exceptions, intended to be payment in full to the hospital for all inpatient costs associated with the beneficiary’s stay. For the appropriate MS-DRGs to be assigned to a claim, a beneficiary must have received 96 or more consecutive hours of mechanical ventilation. A hospital indicates that a beneficiary has met this requirement by using ICD-10 procedure code 5A1955Z—respiratory ventilation, greater than 96 consecutive hours— (ICD-9-PCS code 96.72).

The department still reports the charges that are associated with the CPT® code for initial and subsequent days of ventilation. The HIM coder will assign the applicable ICD-10 code if appropriate.

If a beneficiary received fewer than 96 hours of mechanical ventilation, the stay is assigned to an MS-DRG with a lower severity level, resulting in a lower payment. The claim includes the beginning and ending dates of the beneficiary’s hospitalization, which define the beneficiary’s length of stay in days. The claim also includes the date that the mechanical ventilation procedure started but does not indicate when it ended.


CPT® is a registered trademark of the American Medical Association.

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CPT® copyright 2021 American Medical Association (AMA). All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.