ED Coding and Reimbursement Alert

If you don't meet these documentation requirements, you will not win appeal

When you receive a denial from a payer for critical care services, you should not just give up on payment--nor should you automatically start the appeals process. Look back at the ED physician's op notes for the encounter, and then decide whether to appeal.

Benefit: At times, insurers deny legitimate critical care claims. However, you may also find that the denial was correct, in which case appealing is a waste of time and resources.

When a physician provides services that might be considered critical care, coders need to check documentation to discover:

- the patient's condition that necessitated critical care.
-  how much time did the physician spent with the patient.

Once you-ve answered these questions, you can determine whether your critical care claim was appropriate, experts say.
 
Watch for Keywords About Patient Status

Before you code for critical care services using 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]), make sure the physician documented that the patient's condition warrants critical care.
 
Required: The physician needs to document that the patient is critically ill, which requires that the patient has at least one organ system that is failing and that the patient's life is in jeopardy.

CPT 2006 reports that the patient must have -a critical illness or injury [that] acutely impairs one or more vital organ systems- and requires the physician perform -decision-making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple organ system failure, or to prevent further deterioration.-

According to Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver, ED physicians may treat critically ill patients who:

- are having a heart attack.
- ingested some type of poison.
- overdosed on some type of drug(s).

-Critical care also includes trauma care for patients with severe injuries,- Hammer says. This includes patients who have:

- a gunshot or stab wound.
- extensive injuries from an automobile accident.
- severe burns.
- head trauma due to a fall with a loss of consciousness.

Caution: A patient does not have to be in the intensive care unit (ICU) to be critically ill, and similarly, not every patient in ICU is critically ill, says Pierre Edde, MD, director of the sleep and respiratory services at Uniontown Hospital in Pennsylvania and founder of www.PCSbilling.com.

The key is the -high probability of imminent or life-threatening deterioration in the patient's condition,- Edde says.

Time Is a Critical Factor

Critical care time works on a calendar day. The time does not have to be continuous, but you should make sure the physician recorded the time he spends with the patient in the patient's chart and explains everything he did during that time before you code for critical care services.

Example: The ED doctor provides 70 minutes of critical care to stabilize a patient at 11 a.m. Two hours later, the patient's condition worsens and the physician is again called on to provide another 40 minutes or critical care. Even though the service was not continuous, you can still report all of the critical care time. On the claim,

- report 99291 for the first 70 minutes of critical care.
- report 99292 for the last 40 minutes of critical care.

Don't Rule Out Other Services

If the physician provides critical care services on the same day that he provides other services, don't automatically rule out coding both. You can report another E/M service, such as an initial emergency department or subsequent inpatient visit, on the same date you report critical care, Hammer says.

Example: The physician sees a patient in the afternoon in the ED and performs a comprehensive history, comprehensive exam, and high-level medical decision-making. The patient is admitted to the floor for treatment of a COPD exacerbation. Then, in the late evening, the patient's condition worsens dramatically. The ED physician goes up to the floor to see the patient, urgently ordering a stat portable CXR, nebulizer treatments, and an arterial blood gas. The ED physician provides 40 minutes of critical care services.

You can code for both the critical care services and the initial ED visit service in this example, says Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI, an ED coding and billing company in Stoneham, Mass.

On the claim,

- report 99291 for the critical care service.

- report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive exam; and medical decision-making of high complexity) for the E/M service.

- attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99285 to show that the E/M and the critical care were significantly separate services.