ED Coding and Reimbursement Alert

Beware: CPT, CMS differ on 'family discussion' parameters.

When the physician treats a patient with a critical illness or injury, coders need to know when to start and stop the critical care clock in order to avoid miscoding. Check out this FAQ to find out what's part of critical care, what's not, and how to correctly count the minutes to ensure the most accurate and profitable 99291-+99292 claims.

Be careful when considering critical care minutes; many services that you might think are part of the 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) package are actually separately billable procedures, pointed out Caral Edelberg, CPC, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La., during her recent presentation on ED trauma coding at The Coding Institute's multi-specialty conference in Orlando, Fla. (www.codinginstitute.com).

"The critical care clock stops," explains Edelberg, during separately billable procedures such as CPR; endotrachael intubation; chest tube/central line insertion; ultrasound interpretation; and laceration/orthopedic repairs.

Critical care time also excludes the following:

• teaching time aside from the actual care • most time spent speaking with authorities, family members, or caregivers that do not directly bear on the patient's medical care (There are exceptions to this rule; check FAQ 2 for more info).

Also, don't just use total time the patient spends in the ED, because not all of it is active critical care time.

Example: The physician provides uninterrupted treatment of a critically ill patient for a total of 84 minutes. During that time, he performs CPR for eight minutes, spends three minutes teaching, and discusses the patient's condition with family members for five minutes.

In this instance, the physician provided 68 minutes of critical care (84 " 8 " 3 " 5 = 68), which you'd report with 99291.

Most other services that the physician provides to the critically ill patient are part of the 99291 package. This bundle of services includes: interpretation of cardiac output measurements, x-rays, pulse oximetry, blood gasses, and information data stored in computers (such as ECGs, blood pressures, and hematologic data); gastric intubation; temporary transcutaneous pacing; ventilatory management; and vascular access procedures (though not most central line codes).

'Discussion' exception: Though most interactions with authorities, family members, or caregivers are typically not part of critical care time, there are exceptions, points out Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

"[Critical care] time does not include time speaking with family/authorities -- unless obtaining history or discussing advanced directive matters," Edelberg noted.

CPT and Medicare have specific commentary regarding what types of circumstances and conversations outside of direct patient care may count toward critical care time:

Medicare rules: The interactions are part of critical care when "the patient is unable or incompetent to participate in giving a history or making treatment decisions, and the discussion is necessary for determining treatment decisions," Contreras says.

CPT rules: CPT states that when the patient is unable or clinically incompetent to participate in discussions, time spent on the floor or in the unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient's condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the medical decision making.

If you have any questions about either of these "discussion" exceptions, be sure to clear things up with the payer before deciding what interactions can count toward critical care.

(See the next story on this page for tips on submitting notes on interactions with family during critical care encounters.)

From Medicare Transmittal 1548, July 9, 2008: "The CPT code 99291 is used to report the first 30-74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient by the same physician or physician group of the same specialty.

"CPT code +99292 [... each additional 30 minutes ...] is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care. Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E/M code."

CPT rules: "The language in CPT requires 75-104 minutes for base service (99291) and one segment of +99292," says Edelberg. This means that strictly by CPT definition, you can use +99292 to report even one minute of critical care past 74.

Cautionary note: Though Medicare references the above CPT table in several recent Medicare transmittals, some experts are concerned about reporting critical care of less than 15 minutes beyond the initial 74 with +99292. Be sure to check with your payer if you are unclear on its policy.