By Lisa A. Eramo
The OIG is taking a closer look at mechanical ventilation, according to its FY 2013 Work Plan. Is your hospital doing the same?
In particular, the Work Plan states the following:
We will review Medicare payments for mechanical ventilation to determine whether the DRG assignments and resultant payments were appropriate. We will review selected Medicare payments to determine whether patients received fewer than 96 hours of mechanical ventilation. Mechanical ventilation is the use of a ventilator or respirator to take over active breathing for a patient. CMS requires that claims be completed accurately to be processed correctly and promptly. For certain DRG payments to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation.
William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc. in Fort Walton Beach, Fla. says the OIG, Recovery Auditors, and others are likely targeting these MS-DRGs:
- 003, extracorporeal membrane oxygenation or tracheostomy with mechanical ventilation 96+ hours or principal diagnosis except face, mouth, and neck with major operating room procedure, relative weight 17.7369
- 004, tracheostomy with mechanical ventilation 96+ hours or principal diagnosis except face, mouth, and neck without major operating room procedure, relative weight 10.883
- 207,respiratory system diagnosis with ventilator support 96+ hours, relative weight 5.3619
- 870, septicemia or severe sepsis with mechanical ventilation 96+ hours, relative weight 5.8399
- 927, extensive burns or full thickness burns with mechanical ventilation 96+ hours with skin graft, relative weight 16.4026
- 933, extensive burns or full thickness burns with mechanical ventilation 96+ hours without skin graft, relative weight 2.3740
Note differences between invasive and non-invasive ventilation
Invasive ventilation—otherwise known as mechanical ventilation—is provided through either a tracheostomy or endotracheal tube, Haik explains. A physician inserts the tracheostomy tube through the skin of the neck and into the trachea. He or she inserts an endotracheal tube orally through the mouth or nose and into the trachea. An inflated cuff around the tracheostomy or endotracheal tube keeps the tube in place and prevents air from escaping back from the lungs. A ventilator is then set to a certain volume or pressure, he adds. ICD-9-CM procedure code 96.7x denotes invasive (mechanical) ventilation.
Non-invasive ventilation is provided via a tight-fitting face mask over the nose and mouth. The patient then receives bi-level positive airway pressure (BIPAP), which delivers a preset inspiratory positive airway pressure as well as a preset expiratory positive airway pressure. ICD-9-CM procedure code 93.9x denotes non-invasive ventilation.
Keep in mind that patients can receive BIPAP or continuous positive airway pressure (CPAP) invasively or non-invasively, says Haik. When BIPAP is provided together with CPAP during invasive ventilation, it’s referred to as pressure support ventilation (PSV). However, coders sometimes see BIPAP or CPAP and automatically assume the patient is receiving invasive ventilation, he explains.
“The patient can be extubated and receive BIPAP or CPAP,” he says. “So the key is to count the hours only up until the tube is removed from the patient’s lungs. That’s when mechanical ventilation ceases.”
Understand why physicians perform invasive (ventilation
Physicians perform invasive ventilation for patients with acute respiratory failure who can’t breathe on their own, says Haik. The acute respiratory failure can be due to any one of the following causes:
- Pulmonary etiology (e.g., pneumonia)
- Cardiac etiology (e.g., cardiogenic pulmonary edema)
- Musculoskeletal etiology (e.g., severe amyotrophic lateral sclerosis)
- Trauma (e.g., facial or head injury)
- Drug overdose (e.g., an overdose that causes heavy sedation and an inability to breathe on one’s own)
However, the acute respiratory failure may not be the principal diagnosis.
For example, a patient presents to the hospital with a drug overdose that has caused respiratory failure. The patient quickly undergoes intubation with mechanical ventilation. In this case, the poisoning (drug overdose) is the principal diagnosis due to sequencing guidelines, which means the DRG grouper won’t recognize the mechanical ventilation, Haik explains.
“Hospitals erroneously sequence the respiratory failure as the principal diagnosis when it should have been the drug overdose. That’s a common situation,” he says.
Coders must think carefully when coding—and querying for—acute respiratory failure, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent HIM consultant in Madison, Wis. In particular, they shouldn’t ask physicians whether the patient had acute respiratory failure when documentation doesn’t include any clinical indicators for the condition.
“The patient may be on the vent prophylactically to protect the airways,” he says. For example, a patient who had a stroke and who has a propensity to aspirate may receive mechanical ventilation to prevent aspiration of stomach contents into the lungs. This patient doesn’t have acute respiratory failure, he adds.
Coders should use the following criteria as clinical indicators for acute respiratory failure in a patient whose lungs were previously normal:
- PO2 < 60 mmHg
- PCO2 > 50 mmHg
Coders can use either of the following criteria as clinical indicators for acute respiratory failure in a patient with previously abnormal lungs:
- pH < 7.35 with a PCO2 > 50 mmHg
- A change in the PO2 < 60 mmHg representing a drop of 15 mmHg from the previous normal PO2
Sepsis is another tricky area. If documentation doesn’t clearly support that sepsis was present on admission, then it’s not appropriate to report it as the principal diagnosis, says Haik. However, hospitals may be able to appeal denials for which patients with an infection require mechanical ventilation on admission. “Most people who require mechanical ventilation on admission and who have infections are septic,” he adds.
Count the hours carefully
“The duration of mechanical ventilation is highly scrutinized,” says Haik. Coders shouldn’t solely rely on physician orders when calculating duration. Instead, they should also use respiratory therapy notes and progress notes, which sometimes span multiple days in the record.
“You have to know the exact hour that the patient is extubated,” says Haik. Physicians may write, time, and date an order for extubation, and the patient may not actually undergo the process until an hour or more later. “It’s not when the physician writes the order—it’s when the patient is extubated,” he adds.
Another point to remember is that mechanical ventilation must be continuous unless there’s an inadvertent discontinuation. For example, this can occur when an endotracheal tube kinks, and the physician must replace it, says Haik.
“Mechanical ventilation does end when we wean the patient off the mechanical ventilation, we extubate the patient, and the patient fails,” he says. “Then we have to put them back on the mechanical ventilator. This is not considered continuous.”
Don’t count the number of days the patient is in the facility rather than the number of hours of ventilation the patient receives. Also remember to include the number of hours the patient spends weaning off the ventilator (i.e., the time spent shifting the breathing function from the machine to the patient to allow the patient to breathe on his or her own). Note that Coding Clinic, third quarter 2010, p. 3 includes several questions and answers related to ventilator weaning.
Also consider the following two examples in the Medicare Quarterly Provider Compliance Newsletter, Volume 2, Issue 1, October 2011 that demonstrate incorrect counting of ventilator hours:
Example 1: The patient is a 52-year-old female who was admitted through the emergency room on June 21, 2009. The patient was placed on a ventilator upon admission at 4:44 A.M. and expired on June 24, 2009, at 3:45 A.M. with intubation time of 71 hours. The provider assigned procedure code 96.72 (continuous invasive mechanical ventilation for 96 consecutive hours or more). Documentation in the medical record supports that the patient was on mechanical ventilation approximately 71 hours.
Finding: Based on the number of hours that the patient was on mechanical ventilation, procedure code 96.71 (continuous invasive mechanical ventilation for less than 96 consecutive hours) should have been assigned. This changed the MS-DRG from 207 (respiratory system diagnosis with ventilator support 96 or more hours) to MS-DRG 208 (respiratory system diagnosis with ventilator support less than 96 hours).
Example 2: The patient is an 84-year-old male admitted through the emergency room on May 19, 2009. The patient expired on May 20, 2009. The provider assigned procedure code 96.72 (continuous invasive mechanical ventilation for 96 consecutive hours or more). Documentation in the medical record supports that the patient was on mechanical ventilation approximately 12 hours.
Finding: Based on the number of hours that the patient was on mechanical ventilation, procedure code 96.71 (continuous invasive mechanical ventilation for less than 96 consecutive hours) should have been assigned. This changed the MS-DRG from 870 (septicemia or severe sepsis with mechanical ventilation 96 or more hours) to MS-DRG 871 (septicemia or severe sepsis without mechanical ventilation 96 or more hours with MCC).
Coders shouldn’t count the following:
- The number of hours the patient spends on the mechanical ventilator before he or she arrives at the hospital. See Coding Clinic, third quarter 2010, p. 3.
- The number of hours the patient receives noninvasive mechanical ventilation. See Coding Clinic, fourth quarter 2008, p. 187.
- The number of hours the patient receives manual ventilation. See Coding Clinic, second quarter 2003, p. 17.
- Mechanical ventilation used during surgery unless the patient continues on ventilation for an extended period (several days) after surgery. See Coding Clinic, second quarter 1992, p. 14. Coding Clinic, third quarter 2004, p.11defines ‘several days’ as ‘more than two.’ If a patient receives mechanical ventilation for more than two days postoperatively, assign ICD-9-CM codes 96.71 and 96.04, according to Coding Clinic, second quarter 2006, p. 8.
Always double check the number of hours, and cross-reference this information with the patient’s length of stay, says Krauss. When a patient receives mechanical ventilation for more than 96 hours, but the length of stay is fewer than two days, this is a red flag for auditors, he adds.
The Medicare Code Editor also now includes an edit that prevents payment of the claim if the ICD-procedure code 96.72 doesn’t match the number of days the patient was an inpatient as indicated in the ‘from’ and ‘through’ dates on the billing claim, says Krauss.
Eramo is a freelance writer and editor in Cranston, RI who specializes in healthcare regulatory topics, health information management, and medical coding. You may reach her at leramo@hotmail.com.