Cardiology Coding Alert

Uncover the truth about coding critical care along with other E/M services

What happens to your cardiologist's critical care claims can make or break your reimbursement. Rid your coding practice of these three critical care myths and boost your bottom line.

Myth 1: Reporting Critical Codes and EKG Is OK

If you think you can report procedures such as EKGs when also reporting critical care codes (as long as you have proper documentation), think again.
 
Key: Critical care codes have exclusions that apply to the physician side, not to facility billing. For example, if your cardiologist performs an EKG while providing critical care, you cannot report both the critical care and the EKG. Actually, only facilities can report those "excluded" procedures, says Andrea Clark, RHIA, CCS, CPC-H, founder and president of Health Revenue Assurance Associates in Florida, who presented on emergency department claims at the Fifth Annual Ingenix Essentials conference.
 
Here's a breakdown of the services critical care codes include, according to CPT:
 
• interpreting cardiac output measurements
 
• chest x-rays
 
• pulse oximetry
 
• blood gases and information stored in computers
 
• gastric intubation
 
• temporary transcutaneous pacing
 
• ventilation management
 
• vascular access procedures.

If your cardiologist provides a service not included on this list, you should report it separately from the critical care code.

Myth 2: Critical Care and E/M Service? No Way

Because critical care constitutes intensive time with the patient, some coders believe that you cannot report an E/M service in addition to critical care. That's not always true.
 
Example: Your cardiologist performs 60 minutes of critical care (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and then six hours of an extended discharge (99239).

At first glance, you may think you shouldn't report critical care and discharges on the same day. But "it is not uncommon for you to bill a discharge on the day your cardiologist performed critical care because most likely your cardiologist is billing for the death summary and final discharge paperwork," says Inga Burton, ACS-CA, certified coding specialist at Prima Heart Physicians in Tucson, Arizona. "I would add modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the discharge code (99239) to justify reporting both the critical care and E/M service."

Myth 3: You Can Include the Procedure's Time With Critical Care Time

Watch out if you're including time your cardiologist spends on a separately reportable procedure along with critical care time because you could face a costly audit. Here's how you should be carving out a procedure from the critical care time.
 
Example: The patient is hemodynamically unstable. Your cardiologist provides critical care for the patient for one hour and 30 minutes -- 15 of which he spends placing a central line.
 
When you choose the critical care code, you must decide based on time. But you should not include the time spent putting in the central line, says Erin Forbes, medical billing specialist at Inlet Cardiopulmonary and Associates in Pawleys Island, S.C. According to CPT, "Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time."
 
This means that your cardiologist spent one hour and 15 minutes performing critical care. You should not include the 15 minutes he spent placing a central line. Your codes should be 99291-25 and +99292-25 (... each additional 30 minutes ...)  to account for one hour and 15 minutes of work.
  
Caution: You should always pay particular attention to the amount of time he spent providing critical care because 99291-99292 are time-based codes. For instance, if your cardiologist documents 50 minutes of critical care, you would report 99291. But if he spends less than 30 minutes, you would likely assign either 99232 or 99233 for subsequent hospital care. In other words, your documentation must support the physician's critical care charges.
 
Important: Also, the National Correct Coding Initiative does not bundle the codes for the central line (36556, Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) into critical care, so you can report this in addition.