ED Coding and Reimbursement Alert

CPT 2001 has broadened the definition of 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (... each additional 30 minutes [list separately in addition to code for primary service]). The revised introduction to critical care now reads, A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patients condition. The new definition adds high probability to the CPT 2000 language (which itself had been altered to eliminate a prior requirement that the patient be unstable). ED physicians unaware of the change may hesitate to code for critical care and instead rely on 99285 (emergency department visit for the evaluation and management of a patient ) but this can lead to undercoding and lost reimbursement.

Thoroughly Document Time

To bill 99291 instead of 99285, the physician must document a minimum of 30 minutes spent providing critical care. Time involved performing separately billable procedures should not be counted toward critical care time, stresses Roger P. Holland MD, PhD, FAAFP, physician reimbursement specialist and president of Utilization PRO Inc. Physician progress notes must document the total time involved providing critical care services. If time is not legibly and unequivocally documented, the claim will be subject to recoding or denial.

Time counted toward critical care does not have to be continuous, advises David McKenzie, director of reimbursement, American College of Emergency Physicians in Irving, Texas. According to CPT, Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient provided that the patients condition continues to require the level of physician attention defined as critical care.

Avoid Unbundling of Included Services

Some payers (e.g., Medicare) may not reimburse critical care services on the same day as a procedure with a global surgical period unless billed with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to indicate that the service was above and beyond the usual pre- and postoperative care associated with the procedure. According to CPT, the following services are included in reporting critical care when performed during the critical period by the physicians(s) providing critical care.

Chest x-rays (71010, 71015, 71020)

Blood gases (82273)

Interpretation of cardiac output measurements (93561, 93562)

Information data stored in computers (e.g., electro-cardiographs [EKG], blood pressures, hematologic data [99090])

Gastric intubation (91105)

Pulse oximetry (94760 and 94762)

Transcutaneous pacing (92953)

Ventilator management (94656, 94657, 94660 and 94662)

Vascular access procedures (36000, 36410 and 36600)

Any services performed which are not listed above, CPT continues, should be reported separately.

Example 1: Patient with a broken leg, stable and awaiting transfer: The local emergency medical service brings a motor-vehicle accident victim to the ED. The initial exam reveals a femoral shaft fracture of the left leg. Additionally, the patients distal left foot appears dusky and cool to the touch. Distal pulses are not palpable. The ED physician splints the entire extremity, places a Foley catheter to monitor urine output and starts an IV of D5NS (5 percent dextrose in normal saline solution, often used for renal failure) to maintain cardiac output and minimize the likelihood of shock. He or she then contacts a tertiary hospital. The hospital accepts the patient in transfer but advises that the ambulance will take 60 minutes to arrive. During the 60-minute interval, the ED physician spends 30 minutes in and out of the patients cubicle, checking for pulses, adjusting the splint and monitoring cardiac output. The time spent attending to the patient including initial evaluation, review of the patients skeletal x-rays, discussion of the case with the receiving trauma surgeon and follow-up of the patients condition totals 60 minutes. This excludes time spent placing or adjusting the splint, which is billed separately.

This service meets the critical care requirement of direct delivery by a physician(s) of medical care for a critically ill or injured patient. Furthermore, it involves decision-making of high complexity to access, manipulate and support to treat single or multiple vital organ system failure or to prevent further life-threatening deterioration.

The physician should bill for long leg splint (29505) and 99291 for critical care. Modifier -25 should be appended to the 99291 to designate it as separately identifiable from the application of the splint.

Note: For more information on billing fracture care, see the May 2001 ED Coding Alert, page 33.

Combining Critical Care and E/M Codes

CPT rules usually prohibit billing more than one E/M code per encounter. But a physician may bill Medicare and some third-party payers for critical care in addition to another E/M code for the same patient on the same calendar day if the patients condition throughout the ED course, as well as the physicians documentation, supports combined use of the codes. For example, a patient may undergo a level-four or -five E/M before his or her condition deteriorates to the point that discrete critical care services are needed.

Its not unusual for a physician to perform a history and physical exam, administer an EKG and code 99285 for a patient who presents to the ED with chest pain, McKenzie says. But then, for instance, the patient suffers ventricular fibrillation with the EKG showing signs of a massive myocardial infarction. The treatment that follows to stabilize the patient constitutes critical care.

In such a circumstance, the ED physician can choose one of two options: 1) Combine and bill all services as critical care, based on the time spent with the patient or 2) Bill the E/M and critical care services separately. When choosing the latter, the time spent performing the E/M service cannot be counted toward the critical care time. Additionally, the billed E/M service must separately meet all the documentation requirements listed under CPT for those services.

Time reported as critical care must be spent engaged in work directly related to the individual patients care, whether at the immediate bedside or elsewhere on the floor or unit. Time spent at the nursing station, on the floor reviewing test results or imaging studies, discussing the critically ill patients care with other medical staff and/or family, or documenting critical care services in the medical record could be reported as critical care, even though it does not occur at the bedside. You may also report time spent with family members acquiring a patient history, reviewing the patients condition or discussing treatment toward critical care if the service bears directly on the management of the patient.

Example 2: Patient with cardiac arrest followed by time on the floor: A patient undergoing evaluation for chest pain suddenly collapses. The ED physician directs CPR and intubates. After a successful resuscitation and stabilization, the physician obtains additional history from old medical records and the patients wife. A chest x-ray is reviewed for tube placement. The entire encounter took 90 minutes, 60 of which were spent attending to the patient after the collapse (not including time spent performing the two additionally billable procedures, CPR and intubation). An additional 10 minutes is spent discussing the case, first with the patients family and then with his oncologist.

Under the usual ED E/M codes, if the history, physical exam and medical decision-making qualify as comprehensive the service should be billed using 99285. Intubation (31500) and CPR (92950) should also be reported. Additionally, the physician should bill 99291 (with modifier -25, to indicate a significant, separately identifiable service above and beyond the procedures also billed) for the 60 minutes of treatment following the patients collapse.

Two hours later, the ED physician is recalled to the floor for the same patient, who has now sustained a spontaneous pneumothorax. The evaluation and treatment time for this visit totals 35 minutes, excluding time for placement of a chest tube. The physician should bill the additional 35 minutes (which are above and beyond the 30-74 minutes required of 99291) using add-on code 99292, again with modifier -25 appended. He or she may also code 32020 separately for the chest tube placement.