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ED Coding and Reimbursement Alert

Are You Underplaying the Critical Care Codes?

Published on Sun Dec 01, 2002

You don't need a medical disaster to report codes for critical care in the emergency department. If you're overly cautious about assigning them, you're losing out on a key resource for ED reimbursement.

Code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) is the "most underreported code in the ED," says James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa.

Most emergency departments reserve 99291 and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) for only the most life-threatening and difficult medical scenarios. Too often, coders report a code from the 9928x series, rather than a critical care code even when the critical care code would bring more reimbursement.

Usually, insufficient physician documentation not your coding skills causes the scarcity of critical code claims. "So often, physicians fail to document critical care time on patients whose condition could deteriorate rapidly into a life-threatening situation," says Nettie McFarland, RHIT, CCS-P, at Healthcare Billing Systems Inc. in Daytona, Fla.

If you don't have physician documentation, you can't use a series of codes whose determination relies heavily on it, McFarland says. Only with sufficient documentation can your physician avoid noncompliance and increase reimbursement for his work.

It's your task as a coder to educate your physicians about the payment opportunity they sacrifice if they don't properly understand and document critical care, Blakeman says. Tell them that the ED should, as he suggests, "stop paying for little stuff and charge appropriately for bigger stuff." Here's how:

What Qualifies As 'Time Spent'

According to CPT guidelines, critical care codes report the time physicians spend when "directly" working on the care of a critical patient.

Tell your physicians to subtract the time spent on procedures from their critical care time. Critical care time does not include time spent on separately billable procedures and services.

Apply critical care codes for evaluation and management services when:

  • the physician directly delivers medical care for a "critically ill" or "critically injured" patient
  • the patient has a "high probability of imminent or life-threatening deterioration"
  • the physician documents high-complexity decision-making.

    Critical care does not include the time spent on:

  • activities that occur outside of the ED or on the floor, including telephone calls taken anywhere
  • activities that don't directly contribute to the patient's care, including meetings, and time spent consoling the family (unless that conversation brings up points relevant to patient history, Blakeman says)
  • performing separately reportable procedures or services.

    Critical care codes require that a patient have the immediate potential to become unstable, meaning the patient doesn't have to already be unstable to require critical care.

    Here's an example of an E/M service supporting critical care codes when the patient never becomes unstable. A physician provides care for a patient with a severe allergic reaction: He has hives, is wheezing, and then develops mild stridor. He does not have respiratory failure, but the imminent potential is very real.

    In this case, the presenting problem and not the final diagnosis or condition determines the risk factor of the case. The severe allergic reaction presents the potential for an unstable, high-risk condition, so diagnosing and treating the crisis warrants critical care codes.

    Critical Care Codes and E/M Services

    Critical care codes don't necessarily include all additional E/M services. The ED physician who provides critical care may also render separately billable E/M services to the same patient on the same date, according to language that first appeared in the 2001 CPT book.

    You can report a separate E/M code for the service provided to a patient before her condition changed and required critical care, Blakeman says. Suppose a patient comes into the ED complaining of chest pains, and the physician performs an evaluation and management service. Then the patient goes into cardiac arrest. With sufficient documentation you can report critical care, but you can also use an E/M code for the prior service, he says.

    You can also code for an E/M service provided to the patient after she stabilizes and no longer needs critical care, Blakeman says. Suppose an ED physician provided critical care until the patient no longer required it, but the patient had to wait in the ED while the hospital prepared to transport him to another area. Once the patient was stabilized and awaiting admission, the ED physician performed an E/M service. You can code that service separately, Blakeman says.

    However, Medicare does not pay for an E/M service after critical care is performed. What Medicare does pay is the critical care, even if it occurs before an E/M service.

    Some professionals consider it aggressive to use a second E/M from the 9928X series after a critical patient stabilized. Only your practice and carrier experience can determine if you use critical care codes this way.

    The Physician's Documentation Clears the Claims

    It's all well and good if your ED physician saves lives, but if he doesn't document his actions, his valuable critical care goes unpaid.

    The physician must document critical time spent on the chart, and then date and initial the documentation. The level of critical care codes is determined by "time spent," so the physician's failure to record critical care time prohibits payment. Though Medicare and other payers can "infer" the critical condition of the patient based on limited information, they can't "infer" the time spent on critical care.

    If the physician doesn't document properly, send the chart back to him and ask him to return it within a reasonable time, perhaps four to five days, Blakeman says. Check your state policies, because your state might limit the amount of time a physician has to send a chart back for critical care claims.

    After you receive the full documentation of critical care, you must review it "completely" before assigning critical care codes, McFarland says.

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