Cardiology Coding Alert

Question: During a regularly scheduled office visit for hypertension management, an established patient was exhibiting signs of unstable angina that had lasted for a few days. Following the history and examination, the cardiologist ordered an electrocardiogram (ECG) that revealed ventricular tachycardia. The patient was given intravenous lidocaine and continuous ECG monitoring, and the physician spent 40 minutes with the patient monitoring and examining him and contacting the family and arranging for ambulance pickup and transfer to the hospital. The cardiologist says we should bill the office visit and 30 minutes of critical care. How should we code this? Pennsylvania Subscriber Answer: A physician can perform critical care in any setting. It involves the doctor's directly delivering medical care for a critically ill or injured patient, according to CPT. "Critical care involves high-complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient's condition."

When coding this scenario, you should bill 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and J2000 (Injection, lidocaine HCl, 50 cc) for the intravenous lidocaine.

You should not code for an established patient office visit (99211-99215), the ECG monitoring or the infusion (90780, Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) because they are all considered part of the critical care services.

Because critical care is a time-driven service, the cardiologist must document the total time he or she spends in treating the critically ill or injured patient. Most coding experts agree that the physician should record the time in and time out when providing critical care to denote it more clearly in the patient's record for coding and audit purposes.