# Critical care vs subsequent visit



## kstults (Mar 31, 2009)

Question:
Hospitalist sees a pt for a couple of days with acute respitory failure and bills a 99232 because the patients condition had not changed. The pt is expected to expire within the day. Then goes off service and the next MD bills a 99291 but also does not change anything but billed this service due to the pt being in critical condition. I realize 99291 is also time based and do know this yet which will also be a deciding factor I assume. Any input would be appreciated.
Thank you


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## ARCPC9491 (Mar 31, 2009)

So Dr 1 bills subsequent care for a couple days and Dr 2 bills critical care "because the patient's in critical condition" but you say "nothing has changed" Does the documentation explicity state the patient is in critical condition? Does it state the amount of time spent? Was it atleast 30 minutes? Maybe you should post a few of the notes (names omitted) I can't tell exactly from what you've posted. Dr 1 possibly should have billed 99291 for his days or Dr 2 may have needed to bill subsequent care.. I'm just not sure based on what you've provided us with.


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## kstults (Mar 31, 2009)

This was the limited info I received as I haven't reviewed the notes yet as I am not on sight. Once I access the notes I will post some of the documentation. I had the same thoughts regarding time and documentation so although I did not provide you with much info your feedback helped me know I was headed in the right direction. It may be that the first physician only billed a 99232 because they did not spend at least 30 minutes with the patient. 
Thank you


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## FTessaBartels (Mar 31, 2009)

*Critical care to critically ill*

To bill 99291-99292 the provider must be *providing* critical care services *to *a critically ill patient. (And document time 30 minutes or more)

That does not mean that the patient is necessarily unstable. A patient may be on a ventilator or even ECMO and be stable, but still critically ill. (Conversely we have patients who are vent dependent and go home with their own ventilators ... they're not necesarily critically ill when they come back into the hospital.)

All that being said, I know one physician who will not bill 99291 unless the patient is in imminent danger of death and he's desperately trying to keep the patient alive. Other physicians in the same practice who rotate on and off service with him will code 99291 (appropriately as per the documentation) but Dr A insists on coding 99233 ... and the two different doctor's documentation looks almost identical. 

Nothing I ever said convinced him ... well, ONE time (in the 4 years I worked with him) I read one of his notes and called him ... "John, I'm not a doctor, but this patient sounds really sick to me..." He agreed to change the code to 99291 (yes, he had documented time)

So, maybe your doctor A doesn't think he's providing critical care (even though patient is critically ill). Maybe he thinks the patient isn't critically ill. Maybe he didn't spend at least 30 minutes. 

All those are possibilities. The documentation will tell.

F Tessa Bartels, CPC, CEMC


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