# Help!! can we bill critical care?



## mrolf (Sep 23, 2010)

scenario:  CAH hospital where Dr A delivered c-section with Dr B as assisting.  After delivery the posterior inferior wall of the uterus was bleeding very briskly.The uterus was exteriorized wand the uterine edges were grasped with ring forcips.  There were several areas of arterial bleeds with were stopped with figure-of-8 sutures. Again bleeding remained brisk. Tried several more sutures which did not help. Pitocin running wide open in patient's IV. Uterine massage was continued and the uterus was starting to firm up. However uterus continued to belled. Surgicel  & packing was tried unsuccessfully. Patient's vital signs started to decline. 60/30 BP. Blood products were ordered. Uterine massage was continued. Dr. Specialist was consulted and recommeded trying  Methergine & Hemabate and started to drive to our facility at least 45 min away.So at that time .2mg of Methergine was given IM and packing and pressure was again utilizied. After 15 min not working. At the time Hemabate 2.5 mg given IM. Again we packed for 15 minutes unsuccessfully. By this time she started to receive blood. She had gotten 2 units by this time. We continued to pack until Dr. Specialist could arrive. In the meatime she got two more units of blood. After this she received two units of fresh frozen plasma. We continued to pack the uterus and tried to achieve hemostasis for another 50 minutes after which Dr. SPecialist arrived.
How do you bill this service when both Dr. A & Dr B were treating this patient.  Is this critical care and which doctor would receive this?  Any help would be appreciated.
Thanks.


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## FTessaBartels (Sep 24, 2010)

*I don't think so*

I am NOT an expert in OB/GYN services, but I believe this falls under the global for the C-section.  No additional charges for critical care or any other E/M service postoperatively; this is clearly related to the procedure performed.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## LCJACKSO (Sep 24, 2010)

*Hope this is what you're looking for*

For Dr A and Dr B assisting modifiers can be used. 77 for Repeat procedure or service by another physician.  Also, modifier 22 can be used for increased procedural services.  Documentation supporting Modifier 22 will be required.  CPT Assitant notes CC may be reported. See below - Also, note if the specialist belongs to another group/Tax id etc, he is able to bill his own E/M once he is with the patient. Notes should follow.

According to CPT Assistant April 1997 Volume 7 issue 4:

What is Included in Delivery Services? 
Delivery services include admission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery. Medical problems complicating labor and delivery management that require additional resources should be reported with the Medicine and Evaluation and Management Services codes, in addition to the maternity care codes. If a patient is admitted to the hospital for observation prior to delivery and stays more than 24 hours, then you should report the hospital care rendered, except the day of delivery, separately. 

Coding Options 
Fortunately, there are coding options to report high-risk deliveries. The first option is to add the -22 modifier to the delivery code and provide supporting documentation with the claim. If the third-party payor does not recognize the modifier, your second option would be to code for prolonged physician services using codes 99356 and 99357. 

If the patient is in unstable critical condition, you could report the critical care codes 99291 and 99292, and report any procedures performed during labor management that are not part of the global package, such as cephalic version, ultrasonography, or nonstress testing. 

Hope this helps
LCJ


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