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.

This means, says Sueanne Bicknell, RHIA, CCS-P, CPC, compliance administrator for CPR-Heart Place, a group practice with 65 cardiologists in Dallas, that the care being provided must be at such a crisis level that the physician must devote his or her full time and attention to that one patient. In other words, Bicknell says, he or she cant see other patients during the critical care time being claimed.

If a cardiologist documents that from 11:30 a.m. to 1 p.m. critical care time was provided to a patient, then care could not be provided to other patients during that time, Bicknell says, noting that this is an area auditors examine closely. The auditors will want to determine if the documentation in the physicians charts indicates he or she was seeing other patients. If so, critical care cannot be billed.

Medical Necessity Is Critical

According to the HCFA memorandum, claims for critical care services should be denied if the services are not reasonable and medically necessary. If the services are reasonable and medically necessary but they do not meet the criteria for critical care services, then the services should be re-coded as another appropriate E/M service (e.g., hospital visit).

It goes on to note, Providing medical care to a critically ill patient should not be automatically determined to be a critical care service for the sole reason that the patient is critically ill. The physician service must be medically necessary and meet the definition of critical care services as described previously in order to be considered covered.

What this amounts to, says Terry Fletcher, BS, CPC, a coding and reimbursement specialist in Laguna Beach, Calif., is that although the CPT and HCFA changes have been interpreted by some cardiologist as a green light to bill lots of critical care, little really has changed.

For example, Fletcher says, under the new guidelines, cardiologists still cant bill critical care for intensive care unit rounding visits, which, in any case, are unlikely to meet the time requirements for critical care.

Patient care that does not meet all the critical care criteria should be reported using the appropriate E/M codes (e.g., subsequent hospital care codes 99231-99233, or inpatient consultation codes 99251-99255) depending on the level of service provided.

Time-based Codes

Critical care is a time-based E/M service, which means that the amount of time spent with the patient should be monitored and documented carefully. Although CPT 2000 changed the time description for 99291, the change has no practical effect, says Laura Siniscalchi, RRS, CCS, CCS-P, the education coordinator at Beth Israel Deaconess Medical Center in Boston. The 1999 description said first hour while in 2000 the description reads first 30-74 minutes. Since the add-on code is for each additional 30 minutes and CPTs rules say that at least half the time must pass before time-based codes may be used, 99291 always included critical care through 74 minutes.

99291: 30-74 minutes
99291 and 99292: 75-104 minutes
99291 and 99292 (2 units): 105-134 minutes
99291 and 99292 (3 units): 135-164 minutes
99291 and 99292 (4 units): 165-194 minutes

Note: If critical care lasts less than 30 minutes, you cant bill with critical care codes but must use another appropriate E/M code.

Siniscalchi adds that one significant change to the CPT timetable for critical care codes in 2000 is the instruction that for any critical care time less than 30 minutes, appropriate E/M codes should be used. Previously, CPT said to use 99232 or 99233 (subsequent hospital care), which may have been confusing if these codes were inappropriate for a particular situation (e.g., an admittal).

As it now stands, the first hour of critical care services (defined as 30-74 minutes of documented time) is billed 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). The next half hour (75-89 minutes) would be billed 99292 (each additional 30 minutes [list separately in addition to code for primary service]).

In other words, if a cardiologist documents spending 32 minutes with a patient, an hour of critical care time using code 99291 may be charged (assuming all the other criteria have been met). If the cardiologist sees the patient for more than an hour, another 30 minutes can be billed once the 75- minute point has been documented, and so on.

If the physician sees the patient twice on the same day and provides and documents critical care in both sessions, all time during that day (both sessions) should be rolled into a total critical care time, says Bicknell. For example, if a cardiologist sees a patient at 10 a.m. and provides (and documents) one hour of critical care, then sees the patient again at 2 p.m. and provides a second hour, then coding for that day would be 99291 and two units of 99292.

Cardiologists can include time spent face-to-face with the patient or on the floor reviewing results, conferring with other physicians about the patient and documenting care, according to HCFA. Time spent off the floor or unit and on phone calls, however, may not be included when calculating critical care time.

Medicare also has clarified that physicians may include time with the patients family to get the patients history or discuss treatment, but only if three criteria are met:

1. The patient is incompetent to provide information;

2. The patient is unable to provide information; and

3. The discussion with the family is absolutely necessary for the physician to make a decision on care.

All three of these conditions must be documented in the physicians daily progress note, which, Medicare stresses, must link the family discussion to a specific treatment issue and explain why the discussion was necessary on that day. All other family discussions, no matter how lengthy, may not be counted towards critical care time. Examples of family discussions that do not meet the appropriate criteria include regular or periodic updates of the patients condition, emotional support for the family, and answering questions regarding the patients condition (only questions related to decision-making regarding treatment, as described above, may be counted toward critical care). Telephone calls to family members and surrogate decision makers must meet the same conditions as face-to-face meetings.

Cardiologists should document From and To times to facilitate and speed up payment, Fletcher says, adding that military, or universal times should be noted (e.g., 12:04-13:17). This provides excellent documentation when sending in prepayment review information and also is useful if you have to appeal a denial.

Billing Critical Care During a Global Period

According to the Medicare Carriers Manual (section 4822.A.9), critical care may be paid in a surgical global period if the critical care is above and beyond and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed.

Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be used if the critical care provided is on the same day as a service or procedure that the physician is providing to indicate that the critical care is a significant, separately identifiable evaluation and management service above and beyond routine pre- or postoperative care.

For example, if a cardiologist sees a patient for initial hospital care and dictates the patients health and physical, but later the same day, the patient goes into crisis and the physician provides and documents two hours of critical care time, one unit of 99291 would be billed, as well as two units of 99292 and one unit of 99223 (initial hospital care) with modifier -25 to reflect that the inpatient admission was separate from the critical care.

If the critical care is provided postoperatively within the procedures global period, then modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) should be attached to indicate that the critical care provided is unrelated to the original procedure.

Note: Since 1993, services such as 93503 (insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes) and 92950 (cardiopulmonary resuscitation [e.g., in cardiac arrest]) are not bundled into critical care codes and may be billed separately. CPR has a global period of zero days and is not bundled into the critical care codes. Therefore, critical care may be billed in addition to CPR if critical care is a significant, separately identifiable service, and it is reported with modifier -25. The time spent performing CPR is excluded from the determination of the time spent providing critical care.

Anticipating an increase in the number of critical care claims as a result of its clarification, Medicare also reduced the number of relative value units (RVUs) in the work portion of 99291 and 99292 by 10 percent, from 4 and 2 RVUs to 3.60 and 1.80, respectively. Total number of RVUs for the procedures now is as follows:

99291 5.12 RVUs (2000); 5.64 (1999)
99292 2.64 RVUs (2000); 2.71 (1999)