Everything counts: Ensuring accurate coding and reimbursement for mechanical ventilation

Wednesday, October 14, 2020

As the novel coronavirus (COVID-19) pandemic continues, hospitals may be treating more patients on mechanical ventilation. COVID-19 patients on mechanical ventilation require intensive care and resources, often for extended periods of time. But gaps in documentation and coding can leave hospitals missing out on earned—and much-needed—revenue and leave crucial holes in patients’ medical records.

It’s not uncommon for the sickest COVID-19 patients to require mechanical ventilation, according to Emmel Golden, MD, FCCP, CCDS, chief clinical officer for Enjoin in Eads, Tennessee. Unfortunately, many COVID-19 patients that require mechanical ventilation will need to be on it for longer than 96 hours, making it imperative that hours on mechanical ventilation are correctly documented and coded to reflect the most accurate MS-DRG assignment and reimbursement.

“It’s very important to count those hours correctly because it makes an enormous difference in terms of the MS-DRG weight,” Golden says. “When you look at the number of personnel that it takes to take care of these patients, its more than just the routine patient in the ICU. And then there’s the expense of the PPE.”

Mechanical ventilation for 96 hours or less is assigned to MS-DRG 208, while mechanical ventilation for more than 96 hours is assigned to the higher weighted MS-DRG 207.

Many hospitals continue to struggle with low volumes in traditional revenue-generating service lines, Golden points out. These ongoing revenue woes can imperil hospitals’ ability to provide the robust care patients need and keep much-needed PPE in stock. That makes it more important than ever to ensure that services are appropriately documented, coded, and billed.

So how can hospitals ensure that they’re getting accurate reimbursement for COVID-19 patients on mechanical ventilation, particularly for cases that extend beyond 96 hours? Ensure coding staff properly count hours on mechanical ventilation and understand what constitutes mechanical ventilation.

Generally, physicians will first attempt to manage COVID-19 patients with respiratory symptoms by using noninvasive ventilation, according to Golden. If that method fails, the patient will generally be intubated and placed on mechanical ventilation until he or she can be successfully weaned off it. Noninvasive ventilation isn’t considered mechanical ventilation; therefore, any hours on noninvasive ventilation can’t be included in the count of hours on mechanical ventilation. But determining when mechanical ventilation ends requires a careful and knowledgeable review of the medical review.

“Once the patient is intubated, the clock starts,” Golden says. “The clock stops when the weaning process is complete and the patient is extubated. The hours that are spent weaning count as mechanical ventilation.”

During the weaning process, the patient may be on minimal support for several hours each day. However, the endotracheal tube will still be in place and the patient is not completely liberated from mechanical ventilation, Golden explains.

“They’re not off the ventilator until the weaning process is complete and, in most cases, the endotracheal tube is removed,” he says. “It’s a little bit technical but it makes an enormous difference in that break between 96 hours and greater than 96 hours.”

Physicians don’t explicitly document hours on mechanical ventilation, Golden says. Instead, coders will need to review the medical record to determine the time the patient was intubated and the time the patient was extubated. The hours between those two points are counted as mechanical ventilation, even if other forms of support, such as CPAP, were used during the weaning process.

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