Ventilation Assist and Management: Clarifying Common Questions

During this public health emergency, a lot of talk is centered around ventilators and the critical role this equipment plays in treating patients with COVID-19. Granted, in a time of crisis where hospitals are (or have the potential to be) overwhelmed with patients requiring lifesaving care, documentation and compliance aren’t at the top of the priority list. It’s understandable given the gravity of the situation and the need to focus on providing patient care, locating the necessary supplies to do so, and personal safety and protection.

However, charges will need to be entered and claims still need to be submitted. Questions on ventilation assist and management are among the most common we receive from our respiratory therapy clients. Let’s take a look, answer some of those questions, and help clear up the gray areas.

Ventilation Management Codes

94002    Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day

94003    Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day

The CPT® codes listed above describe invasive ventilation management provided in the hospital observation and inpatient settings specifically. Due to the specificity of the descriptions, these codes are only billable for observation stays or inpatient admissions.

Ventilation management in the hospital is defined as a daily service. The charge generated for the initial day, code 94002, should account for all related costs including ventilator set-up, routine supplies and therapist time. Charges for subsequent days, code 94003, should include routine supplies, including circuit changes, and therapist time. These routine supplies are included in the codes and are not separately reimbursed. Additionally, routine system checks are not separately billable.

The NCCI Policy Manual for Medicare Services also states that, if performed, respiratory flow-volume loop, breathing response to carbon dioxide, and breathing response to hypoxia testing are included in codes 94002–94003.

Ventilation Management in the Emergency Department

Since the descriptions of codes 94002–94003 limit the application to observation or inpatient settings, a question that comes up often is:

• How do we bill for ventilation management provided in the emergency department?

The short answer: you don’t.

Unfortunately, there is no CPT code for ventilation management performed in the emergency department – including instances where the patient expires in the emergency department or is transferred to another facility. Ventilator management services provided by respiratory therapists in the ED are included and captured in the service level of care that is reported for the ED visit.

As a best practice, the cost for respiratory therapy time and supplies should be calculated into the facility charge submitted for the level of care provided and billed for the emergency department visit. Respiratory therapy department staff are encouraged to work with the emergency department to determine how the associated costs for ventilator management will be captured.

If the patient is admitted as an inpatient, or if the patient is transitioned within the facility as an observation stay, then code 94002 can be assigned for the initial day and 94003 for each subsequent day as applicable. Remember that time for the initial day begins with the admission order.

Weaning Time

The time spent weaning a patient off ventilation is not separately billable, the entire duration of the weaning period is included in the management of the patient. The time associated with ventilation management ends when the patient is successfully extubated, and the mechanical ventilation is shut off.

Bilevel Positive Airway Pressure

With the situation hospitals find themselves in trying to deal with the COVID-19 pandemic, the FDA has released guidance on mitigation strategies for ventilator supply. Specifically, modifications to respiratory devices due to this emergency. It should be noted that CPAP machines for obstructive sleep apnea cannot be used as ventilators.

Bilevel devices, however, are ventilators and can be modified and used for invasive ventilation. The American Association for Respiratory Care (AARC) has released guidance and recommendations on how this can be done safely for patients and providers. At this time, no official guidance has been released as to whether these modified devices should be coded as invasive ventilation (using codes 94002-94003) or in the usual fashion. As a reminder, BiPAP does not have a separate, specific CPT code. We are instructed, per the AMA, to use code 94660 (continuous positive airway pressure ventilation [CPAP], initiation and management) for reporting the initiation and subsequent management of BiPAP. As with CPAP, BiPAP services are billed per day, not per hour.

Be sure to continue to monitor information being released by the FDA, CMS, AARC and other organizations as this continues to develop. The current rate of change, as we all know, is unprecedented and information relating to COVID-19 and treatment is subject to change at any time. As more information is released, we will continue to keep you updated.