ED Coding and Reimbursement Alert

Do you know what services are bundled into 99291, 992927

Coding for critically ill patients can give even the most seasoned coder a headache. If you don't prove that the patient is critically ill, the insurer will most likely deny your critical care claim.

Further, you-ll need to know which procedures are included in critical care claims and which aren-t. Check out this list of frequently asked questions on critical care.

Question: What Do Insurers Consider Critically Injured or Ill?

This is perhaps the most vital question you-ll need to answer on a critical care claim. If the patient is not critically ill or injured, you are not allowed to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (... each additional 30 minutes [list separately in addition to code for primary service]), says Greer Contreras, senior director of coding for Marina Medical Billing Service Inc. in California.

-CPT defines critically ill or injured as an injury or illness that acutely impairs one or more vital organ systems such that there is high probability of imminent or life-threatening deterioration in the patient's condition,- he says.

Contreras offers these examples of patients whom insurers would consider critically ill or injured:

- an acute asthma exacerbation patient requiring multiple nebulizer treatments and close monitoring with perhaps the use of third-line agents such as magnesium
- a diabetic ketoacidosis patient requiring large amounts of IV fluid and IV insulin therapy
- a patient with active GI bleeding requiring a saline fluid boluses and/or blood transfusion.

However, the patient -does not have to have unstable vital signs or be unstable in any way [to receive critical care],- says Jim Blakeman, senior vice president at Emergency Groups Office in Arcadia, Calif. -Medicare clarifies this as the state of the patient where the absence of the physician's -direct personal management- would likely result in sudden, clinically significant or life- threatening deterioration,- - he says.

Try this: When the physician is considering whether a patient is critically ill or injured, Blakeman recommends that the physician ask himself: -If I did nothing for the patient for the next hour, what's the likelihood that he would have a clinically significant deterioration?-

-If there is a high probability [of significant deterioration], the patient is critical,- Blakeman says. For example, a patient with atrial fibrillation accompanied by runs of rapid ventricular response is very likely critical, Blakeman says.

Question: Where Can the Physician Provide Critical Care Service?

Anywhere that he treats a critically ill or injured patient. One thing you won't have to worry about on your critical care claims is the place of service.

While most critical care will occur in a critical care area (ICU, ED, etc.), the physician can provide 99291 service anywhere the patient requires it. -Critical care is not limited to a specific area. CPT states critical care is usually, but not always, given in a critical care area,- Contreras says.

Consider this example from Contreras: A patient with worsening shortness of breath presents to the ED. Due to ED overcrowding, the physician sees the patient in the observation area.

The physician examines the patient and finds him to have elevated blood pressure and is tachycardic. The patient is started on a Cardizem drip to control his heart rate. Labs, chest x-ray, and an EKG are ordered. Multiple re-evaluations are performed. The physician interprets both the x-ray and EKG, and the patient is diagnosed with CHF and atrial fibrillation. The EKG interpretation takes the physician four minutes, and the rest of the encounter took 46 minutes.

In this example, the physician spent 46 minutes providing critical care services to this patient (this time excludes time spent interpreting the EKG). On the claim, you would:

- report 99291 for the 46 minutes of critical care
- report 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for the EKG.
- link 786.05 (Shortness of breath), 428.0 (Congestive heart failure, unspecified) and 427.31 (Atrial fibrillation) to 99291 and 93010 to prove medical necessity for the services.

On this claim, -you would not code the chest x-ray interpretation, as it is included in the critical care code,- Contreras says.    

Question: What Services Are Bundled Into Critical Care Codes?

Along with x-rays, these services are also bundled into 99291 and 99292:

- interpretation of cardiac output measurements
- interpretation of pulse oximetry
- interpretation of data stored in computers
- trancutaneous pacing
- ventilator management
- some vascular access procedures
- gastric intubation.

Best bet: When your physician provides any of the above services during a critical care session, do not report them separately.

Non-bundles: On your critical care claims, report these services separately from 99291 and 99292 because they are not bundled into critical care:

- CPR
- endotracheal intubation
- pericardiocentesis
- EKG interpretations
- central venous catheter placement.

But be sure to deduct the time spent providing any of these separately billable procedures from your critical care time reported.

Question: Should I Document Critical Care Start and Stop Times?

This step is unnecessary; all you have to do is add up the critical care time and report that number, Blakeman says.

-CMS ruled out this criterion in 2000, when they clarified that critical care was a cognitive service not dependent upon external proxies of time. Time is dependent upon the physician's cognitive work, not the physical location (e.g., bedside) or unit time,- he says.

Do this: -The physician should report her aggregate time. While you do need the total time spent providing critical care documented, it is not a requirement to include each specific start and stop time,- Contreras says.

Suppose the physician provides critical care for a patient from 11:45 a.m. until 12:45 p.m. The physician then goes on rounds for two hours and is called back to the critical patient due to a deterioration of his condition. The physician provides more critical care for the patient from 3 p.m. until 3:45 p.m.

On your claim, you just have to report the total critical care time; don't worry about documenting the individual start/stop times. So in this instance, you should report 99291 for the first 74 minutes of critical care and 99292 for the remaining 31 minutes of time.