Cardiology Coding Alert

Although the words unstable and constant may have been removed from CPT critical care code (99291-99292) guidelines, cardiologists still need to use these relatively well-reimbursed evaluation and management (E/M) codes carefully and shouldnt use them to bill for rounds in the critical or intensive care unit.

In fact, the rules for billing critical care remain stringent. Although patients no longer need to be unstable, according to CPTs revised definition, the patient must have a critical illness or injury [that] acutely impairs one or more vital organ systems such that the patients survival is jeopardized. The care of such patients involves decision making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple organ system failure, or to prevent further deterioration.

And although physicians no longer have to provide constant care to the patient, they still must devote their full attention to the patients care.

Medicare has weighed in on the changes to critical care outlined in CPT Codes 2000 in a bid to clarify its own guidelines. In a memorandum, the Health Care Financing Administration (HCFA) notes that the term unstable is no longer used in the CPT definition to describe critically ill or injured patients. The transmittal then goes on to list two new review criteria that must be met over and above the new CPT Guidelines for critical care claims.

Clinical Condition. There is a high probability of sudden, clinically significant, or life-threatening deterioration in the patients condition that requires the highest level of physician preparedness to intervene urgently.

Treatment. Critical care services require direct personal management by the physician. They are life and organ-supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis likely would result in sudden, clinically significant or life-threatening deterioration in the patients condition.

In addition, while noting that CPT 2000 eliminated the requirement for constant attention as a prerequisite for use of critical care codes, the transmittal also reminds providers that, according to the new CPT description, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time. It goes on to state flatly that, according to Medicare, the deletion of the requirement for constant attention is editorial, e.g., the intent of the full attention requirement is the same as the constant attention requirement.

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