ED Coding and Reimbursement Alert

A December 1999 program memorandum from the Health Care Financing Administration (HCFA) makes life easier, if not better, for emergency departments. The good news is that the definition of critical care has been clarified for Medicare claims. The bad news is that HCFA believes the new regulations will result in more critical care billing, so reimbursement has been reduced.

Critical care has changed, says Robert Kottman, MD, FACEP, president of Alamo Physicians Services Inc., an emergency physician billing service in Universal City, Texas. Medicare thinks the new guidelines will cause more billing and the time-related requirements could cause problems.

Recent Regulations

The new rules, while clarified, still need to be more specific before critical care benefits will be paid. Here are four of the HCFA program memos key provisions:

1. Physicians must be precise in their documentation of critical care. Critical care time can be divided into smaller segments. For instance, a physician who performs critical care services in units of 20 minutes, 15 minutes, and 10 minutes separated by time spent on other procedures billable with evaluation and management (E/M) codes could bill for 45 minutes of critical care under CPT code 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). Each additional 30 minutes is coded under 99292. Physicians who perform less than 30 minutes of services cant bill critical care to Medicare and must, instead, bill with the emergency department evaluation and management (E/M) codes.

2. Critical care time cant include other billable services. According to Peter Sawchuk, MD, chairman of the American College of Emergency Physicians (ACEP) Coding and Nomenclature Advisory Committee, member of ACEPs CPT Advisory Committee and practicing physician at Eidos Healthcare Resources in Green Pond, N.J., If critical care is being provided for an arrest and a physician provides CPR services, critical care would be a separately identifiable service and should be coded separately. Technically, the provider cannot provide two services at the same time. So, basically, you stop the count of critical care time. If the physician ceases CPR and someone else takes over, then the physician resumes the critical care. That can restart the clock.

3. Critical care requires the full attention of the physician. If the emergency department (ED) doctor spends time treating other patients or performing any other services not directly related to the patient requiring critical care, that time cannot be billed under E/M codes 99291 or 99292.

4. Diagnostic interpretation and treatment discussions with the patient or family are considered critical care. Kottman asserts, In general, E/M codes and critical care codes are mutually exclusive. Thats not always the case, but generally, if youre going to charge critical care, you cant charge evaluation and [...]