ED Coding and Reimbursement Alert

The coding of critical care services presents a challenge for emergency department coders because one or more of the required descriptors or indications of the urgent and critical nature of the care often are omitted from the physicians notes. The following case study provides an opportunity to revisit the qualifiers for coding critical care for the Medicare and non-Medicare patient.

Chief Complaint: Elevated heart rate.

HPI (history of present illness): The patient is a 42-year-old female brought in by EMS (emergency medical services) with a heart rate of 160 at the nursing home. They noted the patient to be somewhat sluggish. They noted her level of consciousness to be decreased and that she has a fever. The patient is unable to communicate.

PMH (past medical history): PMH is significant for problems related to mental retardation, intestinal obstruction, cerebral palsy and dysphagia, requiring PEG-tube (percutaneous endoscopic gastrostomy). The patient has had colon and ileal resections in the past.

Social History: She is a patient at a rehab facility.

Physical Examination:

Patient Status: An ill-appearing white female. She
is thin.

HEENT (head, eyes, ears, nose and throat): Her eyes are open. She does not respond.

Neck: Shows no JVD (jugular venous distention).

Lungs: Clear.

Cardiovascular: Tachycardic and regular.

Abdomen: Soft. No obvious tenderness.

Buttocks: Shows bilateral gluteal erythema with large draining purulent abscess site. This is the same site where she has had problems with bedsores in the past.

Extremities: Without cyanosis or edema.

Skin: Significant for the cellulitis in the buttocks.

Emergency Department Course: On arrival at 4:55 a.m., we were unable to get any blood pressure. She did have femoral pulses. Her heart rate was 210 to 220. It was wide complex. The suspicion was supraventricular tachycardia (SVT) with aberrancy, and the patient was given adenosine 6 mg IV push. She had spontaneous change to a sinus tachycardia. She was noted to be febrile at 100.5 degrees rectally. At 5:30 a.m., her family arrived. They stated that the patient is usually nonverbal, moans and does not follow commands. They thought she recognized them.

Diagnostic/Laboratory Test Results: Lab work showed multiple abnormalities including an elevated BUN (blood urea nitrogen) of 183, creatinine 4.3, and calcium 7.3. The cardiac enzymes were not elevated. Her white count was 12.9, H&H (hemotocrit and hemoglobin) 7 and 22. EKG (electrocardiogram) after conversion with adenosine showed a heart rate of 113 and normal sinus rhythm with no evidence of ischemia. Her urinalysis here showed pyuria with 22 white blood cells.

Level of Service: There was greater than one-half hour direct physician intervention and critical medicine including patient management, consultation with PMD (private medical doctor) and interaction with family.

EDC/MDM: The patient was admitted to the IMS (internal medicine service) at 8:35 a.m. Old chart was obtained.

Impression:

1. Supraventricular tachycardia with aberrancy with subsequent cardiogenic shock.

2. Acute febrile illness with buttocks cellulitis/abscess.

Treatment/Plan: The patient was admitted to ICU (intensive care unit).

Codes assigned:

Code 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

Code 93042 (rhythm ECG, one to three leads; interpretation and report only).

Case Discussion

In this non-Medicare case, the physician provides a clear indication of the qualitative and quantitative components of care, particularly as the patients family must be included in efforts of the physician due to the patients inability to provide any information herself.

Clearly, the time spent managing the patient is a significant indicator and must be documented by the physician or easily inferred from a review of the record for non-Medicare patients billed under the CPT guidelines. Medicare, however, in its Transmittal No. B-99-43 dated December 1999, refines the reporting of the time a little differently than the descriptors in CPT.

Medicare Policy for Coding Critical Care

From a clinical standpoint, critical care applies to the patient condition(s) with a high probability of sudden, clinically significant or life-threatening deterioration in the patients condition. Care of the critical patient requires the physicians immediate availability and calls for urgent intervention, as is the case in the emergency department.

Treatment requires direct personal management by the physician that may include life- and organ-supporting interventions and frequent, personal assessment and manipulation by the physician. Documentation must establish that the withdrawal of, or failure to initiate, these interventions on an urgent basis likely would result in sudden, clinically significant or life-threatening deterioration of the patients condition.

When patients are unable or clinically incompetent to discuss their condition or provide any additional information required by the physician, time spent with family members or others to obtain and document a medical history, review the patients condition or prognosis, or discuss treatment options may be reported as critical care.

Documentation of critical care, under Medicare guidelines, requires:

The physicians progress note to contain documen- tation of the total time involved providing critical care services.

Time to be legibly and unequivocally documented on the claim.

The physicians note to indicate that time involved in the performance of separately billable procedures was not counted toward critical-care time. Time involved performing procedures that are not bundled into critical care and billed separately may not be included and counted toward critical-care time.

Medicare guidelines differ from those outlined in CPT. Refer to the Correct Coding Initiative for information on the services included in the critical-care code.

Use of Modifier -25 for Medicare

Critical care cannot be paid on the day the physician also bills a procedure code with a global surgical period unless it is 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).

The Health Care Financing Administration (HCFA) recognizes that some carriers do not permit payment for the critical care on the same day as a procedure with a global surgical period even if it is billed with modifier -25. But according to Medicare policy, separate payment may be made for critical care in addition to these services if the care was a significant, separately identifiable service and it was reported with modifier -25.

Remember, the time spent performing any unbundled services is excluded from the determination of the time spent providing critical care. According to HCFA, Medicare carriers must apply this policy to any procedure with a 0-, 10- or 90-day global period. For example, cardiopulmonary resuscitation (CPR) (92950), has a global period of 0 days and is not bundled into the critical care codes. Therefore, this care may be billed in addition to CPR if its reported with modifier -25.

The time spent performing CPR is excluded from the determination of the time spent providing critical care.

CPT Policy for Coding Critical Care

Critical care is the direct delivery by a physician or physicians of medical care for a critically ill or injured patient with one or more acutely impaired vital organ systems such that the patients survival is jeopardized.

The medical decision-making for critical patients is of high complexity. Examples of conditions that require this type of care include assessment, manipulation and support of central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection or other vital system function.

Note that even if the patients vital signs are stable, services to patients with high risk of mortality or morbidity are considered critical care.

The following services are included in the critical-care package and would not be reported separately: the interpretation of cardiac output measurements (93561, 93562), chest x-rays (71010, 71020), blood gases, analysis of data stored in computers (99090), gastric intubation (91105), temporary transcutaneous pacing (92953), ventilator management (94656-94662) and vascular access procedures (36000*, 36410*, 36415*, 36600*). Any other services performed during the patients emergency department (ED) course should be reported separately.

The time spent providing critical-care services to critically ill or injured patients does not need to be continuous. To code critical care, the physician must devote his or her full attention to the patient during the time billed. The doctor is not required to provide those services at the patients bedside.

Critical-care time may include time spent engaged in work directly related to the patients care at the immediate bedside or elsewhere in the ED. CPT uses the example consistent with time spent in the ED or at the nursing station reviewing test results or imaging studies, discussing the patient with other medical staff, or documenting the medical record even though these activities would not occur at the bedside.

If the patient is unable or clinically incompetent to participate in discussions, time spent with family members or others obtaining a medical history, reviewing the patients condition or prognosis or discussing treatment or limitations of treatment may be included in the time spent providing patient care.