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 [...]