The ICD-10-PCS provides three codes to describe the duration patients are on mechanical (respiratory) ventilation as follows:
5A1935Z Respiratory ventilation, less than 24 consecutive hours
5A1945Z Respiratory ventilation, 24-96 consecutive hours
5A1955Z Respiratory ventilation, greater than 96 consecutive hours
Mechanical ventilation is a process by which gases are moved into the lungs by means of a mechanical device that assists respiration by augmenting or replacing the patient’s own ventilatory effort. With mechanical ventilation, the patient is either intubated or receives a tracheostomy and a variable degree of assistance is delivered to meet respiratory requirements in an uninterrupted fashion.
Start counting the duration of mechanical ventilation with one of the following:
- Endotracheal intubation (and subsequent initiation of mechanical ventilation),
- Initiation of mechanical ventilation through a tracheostomy, or
- At the time of admission of a previously intubated patient or a patient with a tracheostomy who is on mechanical ventilation
When assigning codes for mechanical ventilation, the coder should review the health record to determine if the patient was on mechanical ventilation for less than 24 consecutive hours (code 5A1935Z); 24-96 consecutive hours (code 5A1945Z); or greater than 96 consecutive hours (code 5A1955Z). These codes would not be reported to capture mechanical ventilation that is being used during a surgical procedure. The ventilatory support that is provided to a patient during surgery is considered an integral part of the surgical procedure and is not coded separately.
Endotracheal (ET) intubation requires nonsurgical placement of the tracheal tube. The ET tube can either be placed orally or nasally. ICD-10-PCS provides two codes describing insertion of ET tube as follows:
0BH17EZ Insertion of endotracheal airway into trachea, via natural or artificial opening
0BH18EZ Insertion of endotracheal airway into trachea, via natural or artificial opening endoscopic
Whether or not endotracheal intubation is coded in addition to mechanical ventilation is addressed in the question and answer examples provided below.
For those patients who are intubated for mechanical ventilation prior to admission, begin counting the duration at the time of admission. When a patient receives mechanical ventilation over an extended period, a tracheostomy may be surgically created in the anterior cervical trachea to prevent damage to the larynx and to provide improved pulmonary toiletry. A tracheostomy can be performed either at the bedside or in the operating suite. Patients with a tracheostomy often have a tracheal tube inserted, which keeps the tracheostomy open and allows for the attachment of the mechanical ventilator. Begin counting the duration of mechanical ventilation via a tracheostomy when ventilatory support starts.
Occasionally, the endotracheal tube will need to be replaced due to mechanical problems (e.g., leakage of the cuff). The removal and immediate replacement of an endotracheal tube is counted as part of the initial duration. For those patients receiving mechanical ventilation via endotracheal intubation, and who later receive a tracheostomy through which mechanical ventilation continues, the duration is counted beginning at the start of intubation. The duration would continue through the time in which the tracheostomy is used. Examples of indications for tracheostomy can include, but are not limited to:
- Extended intubation due to acute illness
- Subglottic stenosis due to trauma
- Obstructive sleep apnea
- Congenital anomalies of larynx or trachea
- Head or neck trauma
- Inhalation of corrosive smoke or steam
- Airway obstruction
- Risk of aspiration due to paralysis of muscles related to swallowing
- Coma or extended period of unconsciousness
When the patient is being weaned from mechanical ventilation, the entire duration of the weaning process is counted to determine the correct code assignment. There may be several attempts to wean the patient off of the ventilator prior to extubation. The duration includes the time the patient is on the ventilator, the actual weaning, and the ending, when the patient is extubated and mechanical ventilation is turned off (after the weaning period).
After the patient has been stabilized and is no longer in need of continuous ventilatory support, various weaning methods can be employed to allow for complete discontinuation of the ventilator. The purpose of weaning is to allow the patient to gradually resume spontaneous breathing, while being continually monitored. However, not all patients on mechanical ventilation require a period of weaning.
There are various methods of weaning, including but not limited to the use of T-tubes, intermittent mandatory ventilation (IMV), and pressure support ventilation (PSV). With these weaning methods, there can be periods when the mechanical ventilator is not in use. These weaning procedures are used in conjunction with the patient’s spontaneous breathing until the patient meets established clinical criteria and can totally support his or her own respiratory needs.
After mechanical ventilation has ended, the patient’s condition may deteriorate, requiring subsequent mechanical ventilation during the same hospitalization. This subsequent episode of mechanical ventilation is also reported. Assign separate codes for each episode of continuous mechanical ventilation.
Respiratory modalities involved with mechanical ventilation, such as intubation, extubation, weaning, and tracheostomy creation are all documented within the health record. Most often documentation is recorded on the respiratory therapy record. Other sections in the record where documentation can be found include physician orders, physician progress notes, and nursing notes.
The following examples are provided as additional illustrations:
A patient was admitted in acute respiratory failure, and was intubated and placed on mechanical ventilation for 23 hours. Should the endotracheal (ET) intubation be separately coded along with the mechanical ventilation?
In ICD-10-PCS is endotracheal (ET) intubation coded with mechanical ventilation when the patient receives ventilatory support for surgery?
Under normal circumstances, mechanical ventilation that is being used during a surgical procedure is not coded separately, and neither is the endotracheal intubation. If, however, the patient remains on mechanical ventilation for an extended period (several days) postsurgery, the mechanical ventilation should be reported. Even if the postsurgical patient is not extubated within the expected postoperative time frame, and requires extended mechanical ventilatory support, the ET intubation would not be “retroactively” coded.
When does one start counting the duration of mechanical ventilation for a patient who is intubated and begun on mechanical ventilation in the emergency department and is later admitted to the same hospital?
Begin counting the duration of mechanical ventilation at the time the patient is intubated in the emergency department, if the patient is subsequently admitted to the same hospital. In that situation code both the mechanical ventilation and endotracheal intubation.
However, if a patient is intubated and begun on mechanical ventilation in the emergency department of a hospital and is then transferred to a second hospital for admission, you would begin counting the duration of mechanical ventilation for the second hospital at the time of the admission. When the patient is transferred from Hospital A to Hospital B, already intubated, assign a code only for the mechanical ventilation.
A patient status post tracheostomy was admitted as an inpatient on mechanical ventilation. Five days later the tracheostomy was removed and the patient was successfully weaned off of the ventilator. How should the hours of mechanical ventilation be counted during the weaning process?
All of the period of weaning is counted during the process of withdrawing the patient from ventilatory support. The duration includes the time the patient is on the ventilator, the weaning period, and ends when the patient is extubated and the mechanical ventilation is turned off (after the weaning period).
Previously published Coding Clinic advice regarding the counting of mechanical ventilation hours for patients admitted for weaning assumed that the patient was already on mechanical ventilation at the time of admission. However, our question relates to patients admitted to a long term care hospital on a T-piece or tracheostomy collar the day of the transfer, but placed on mechanical ventilation that evening. How are the hours of mechanical ventilation counted? Should we begin counting hours at the start of the admission even though the patient is breathing through the T-piece without mechanical ventilation, or should the hours be counted from the time the patient is on the vent?
You should begin counting at the start of the admission. All of the period of weaning is counted during the process of withdrawing the patient from ventilatory support. The duration includes the time the patient is on the ventilator, the weaning period and ends when the patient is extubated and the mechanical ventilation is turned off (after the weaning period). The fact that a T-piece is being used during the day does not affect code assignment. A T-piece (trach-collar) trial involves the patient breathing through a T-piece without ventilatory assistance for a set period of time.
A patient, who had suffered acute respiratory failure, is admitted to the long term care hospital (LTCH) for ventilator weaning. On day one, the weaning trial was stopped after 12 hours. On day two, the weaning trial was discontinued after 16 hours. The patient tolerated a weaning trial of 18 hours on the third day. By day four, the patient had several more hours of monitored weaning and was breathing spontaneously on his own. On day five, the ventilator was turned off and the patient was extubated. According to clinical protocol at our facility, a patient is not “officially” weaned until he has been totally off of the ventilator for 72 hours. After the patient successfully completes the weaning trial, he is continually evaluated. Can we count the additional 72 hours as vent time, since evaluation and monitoring is part of the weaning process?
Assign ICD-10-PCS code 5A1955Z, Respiratory ventilation, greater than 96 consecutive hours, since the ventilator was turned off on day five. After the mechanical ventilator is turned off, it is inappropriate to continue to count ventilation hours, even though the patient is continually being evaluated. The additional 72 hours that the patient is evaluated is not included in the ventilation time.
A patient is admitted to a long-term care hospital from an acute care facility with persistent respiratory failure following traumatic quadriplegia after being involved in a motor vehicle accident. The patient is being maintained on continuous positive airway pressure [CPAP] via a tracheostomy. Since the patient is receiving CPAP for 45 hours via his tracheostomy would this be considered mechanical ventilation?
Continuous positive airway pressure delivered via a tracheostomy is coded as mechanical ventilation. Assign the following ICD-10-PCS code:
5A1945Z Respiratory ventilation, 24-96 consecutive hours
The patient is status post tracheostomy and bi-level positive airway pressure (BiPAP) is being delivered via the patient’s T-tube. The patient remained on BiPAP for 48 hours. What is the appropriate ICD-10-PCS code when BiPAP is delivered via a tracheostomy?
BiPAP delivered through an endotracheal tube or tracheostomy is coded as mechanical ventilation. Assign ICD-10-PCS code as follows:
5A1945Z Respiratory ventilation, 24-96 consecutive hours
The BiPAP Ventilatory Support System is a continuous ventilator used for spontaneously breathing patients in critical care or life-supporting applications in the hospital setting. The system may be used for noninvasive treatment (patients are not intubated) of respiratory failure, respiratory insufficiency, and obstructive sleep apnea in patients with spontaneous breathing. What is the appropriate ICD-10-PCS code assignment for the BiPAP S/T-D Ventilatory Support System?
The BiPAP system is a noninvasive ventilation support system designed to augment a patient’s ability to breathe on a spontaneous basis. The code assignment depends on the number of hours that the patient receives BiPAP. The ICD-10-PCS codes that describe BiPAP are as follows:
5A09357 Assistance with respiratory ventilation, less than 24 consecutive hours, continuous positive airway pressure
5A09457 Assistance with respiratory ventilation, 24-96 consecutive hours, continuous positive airway pressure
5A09557 Assistance with respiratory ventilation, greater than 96 consecutive hours, continuous positive airway pressure
BiPAP may also be delivered invasively through an endotracheal tube or tracheostomy and is classified to the root operation “performance.”
A patient diagnosed with a head and neck malignancy undergoes wide excision of tongue, bilateral modified neck dissection and tracheostomy. During surgery, he was placed on mechanical ventilation and weaned to a tracheal mask the following day. Oxygen was then delivered via the tracheal mask. What is the appropriate ICD-10-PCS code assignment for oxygen delivered via a tracheal mask?
Oxygen delivered via a tracheal mask is not mechanical ventilation. It is a method to provide supplemental oxygen. A tracheostomy tube (T-tube) fits inside the stoma and is secured by a harness to the neck. The T-tube may be used by some patients in need of oxygen therapy. Oxygen can be delivered directly through the tracheostomy via a T-tube or a tracheal mask placed directly to the stoma. Mechanical ventilation delivered via a tracheal tube directly into the stoma would be coded as mechanical ventilation.
The administration of oxygen is usually not coded.
How are the hours counted for a patient on mechanical ventilation only at night?
If the patient is on mechanical ventilation only at night (e.g. for treatment of sleep apnea), and the patient is not being weaned, count the duration that the patient was actually put on the ventilator. For each overnight use, assign code 5A1935Z, Respiratory ventilation, less than 24 consecutive hours. For patients being weaned from intermittent (nocturnal) ventilation, calculate the entire weaning trial, including the time the patient is on the ventilator, the weaning period up until the patient is extubated, and the ventilator is turned off.