Anesthesia Coding Alert

Let these four guidelines keep you on track.

As healthcare systems continue to grapple with all aspects of caring for patients affected by COVID-19, more anesthesiologists are being called upon to assist with critical care situations. Since this is an area you might not report on a regular basis, take time to remind yourself of the most important guidelines.

Guideline 1: Meet the Patient and Provider Criteria

Before reporting critical care services, be sure you have clear documentation that the patient — and your provider — meet baseline criteria.

Anesthesia perspective: An anesthesiologist can bill for critical care services. Now, according to 2020 National Correct Coding Initiative guidelines, a certified registered nurse anesthetist (CRNA) also can, says Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

The updated guideline reads, “In certain circumstances, critical care services are provided by the anesthesiologist. CRNAs may be paid for E&M services in the critical care area if state law and/or regulation permits them to provide such services. In the case of anesthesiologists, the routine immediate postoperative care is not separately reported except as described above. Certain procedural services such as insertion of a Swan-Ganz catheter, insertion of a central venous pressure line, emergency intubation (outside of the operating suite), etc., are separately payable to anesthesiologists as well as non-medically directed CRNAs if these procedures are furnished within the parameters of state licensing laws.”

Patient perspective: A patient must meet certain requirements for critical care from both CPT^® and from the insurer’s policy requirements before a service can be classified as critical care. In brief, the patient must have a critical illness or injury that acutely impairs one or more vital organ systems to the extent that there is a “high probability of imminent or life-threatening deterioration in the patient’s condition.” Respiratory failure (such as that associated with COVID-19) meets this definition.

Guideline 2: Pay Attention to Circumstances More Than Location

One common misconception about critical care coding is that the care must be performed in the neonatal intensive care unit (NICU), pediatric ICU (PICU), or the ICU. However, justification for critical care services is not determined by the care location or whether the patient is on a ventilator.

While “critical care is typically performed in a hospital setting, there is nothing in the book that states it is limited to the hospital setting,” adds Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

“Most, but not all, patients that are critically ill are transported to the hospital,” Holle continues. “Every now and then, however, we can use medications and treatments in the office setting to bring them out of a critical care situation. Typically, these are respiratory issues, though they can be neurologic as well,” says Holle.

Guideline 3: Confirm the Services Meet Criteria

Critical care service must be rendered outside of the anesthesia time and pre-and postoperative care services routinely performed by the anesthesiologist. In addition, the same documentation requirements apply to the anesthesiologist as any other provider.

The criteria that must be met before billing for critical care services are:

• The patient must meet the definition of critically ill/injured (vital organ failure; life-threatening health condition).
• The physician must perform the critical care service.
• The critical care service must span a cumulative time of at least 30 minutes on a given date of service; any critical service provided for less than 30 minutes should be billed with the appropriate E/M code.

If the situation and the anesthesiologist’s documentation meet critical care criteria, you’ll report these codes, based on the amount of time involved:

• 99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
• +99292. ... each additional 30 minutes (List separately in addition to code for primary service)

“Critical care is … determined … by the nature of the care being delivered and the condition of the patient,” says Jessica Miller, CPC, CPC-P, CGIC, Manager of Professional Coding for Ciox Health in Alpharetta, Georgia.

To determine whether a patient meets the critical care clinical criteria, you should first “ask and answer the following questions about the service. If the answer is ‘no’ to any of these, do not code as critical care,” Miller says. Those questions, as Miller asks them, are:

• Does the record demonstrate the patient has an acute impairment of one or more vital organ systems and has a high probability of imminent or life-threatening deterioration?
• Does the record demonstrate “High-complexity decision making to assess, manipulate, and support vital system function(s); to treat single or multiple organ system failure; and/or prevent further life-threatening deterioration”?
• Does the record demonstrate that a “sudden, clinically significant or life-threatening deterioration in the patient’s condition” would result if the provider failed to initiate certain specific and urgent interventions?

If the answer to each of Miller’s questions is yes, then you can apply critical care codes 99291 and +99292, as appropriate.

Guideline 4: Check the Documentation

As with any claim you file, documentation is one key to appropriate reimbursement.

Tip 1: “Critical care does not require history, exam, or MDM [medical decision making], but it should be indicated by statements such as ‘patient presents in critical condition due to severe respiratory distress,’” says Holle.

Tip 2: For codes 99291 and +99292, you must document the amount of time spent in critical care by the provider using statements such as “total time in critical care 38 minutes.” This means noting stop and start times, which is routine recordkeeping for anesthesia providers.

Time records should also include “documenting family discussions with and without the patient present, as they are appropriate to count as critical care time,” Miller says. In fact, all time spent in care for the patient who requires critical care is counted — including discussions with other providers or staff involved with the care.