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 management service. That is, unless the patient first receives the E/M service, and then their condition deteriorates and the patient either becomes critical or potentially unstable.

Handling the Changes

Even though these guidelines offer a clear distinction between critical care and E/M services, they will create new problems, primarily complicating record keeping and causing conflicts with payers. Theoretically, there shouldnt be any documentation problems, Sawchuk says. E/M services are provided, then critical care follows later in the encounter. The problem develops not so much in the documentation or the coding but in the payers perception of the service.

For example, CPT allows the billing of E/M and critical care services on the same date by the same provider. The only statement that Medicare makes specifically is that if a patient presents to the emergency department in critical care, E/M wont be recognized on the same day, Sawchuk asserts. Theres no statement about E/M, then critical care, so payers should accept the CPT sequencing of E/M and then critical care. But payers will often not recognize the sequencing and make their own payment policy.

There is no easy solution for this problem. Facilities or physicians who run into trouble with payers regarding critical care must address the issue individually with each payer, attempting to negotiate a better arrangement. Private payers are not obligated to follow the Medicare guidelines.

Documenting Time Is Essential

The time aspect of critical care will require physicians to keep track of their time accurately. If youre going to submit the code, there must be documentation by the physician, Kottman says. That requirement sounds simple, but in the midst of a tense situation when doctors and nurses are striving to treat a critical condition, its easy to forget about time-keeping.

The national program memorandum says physicians must make a statement in the project notes regarding the time for critical care, Sawchuk says. That rule allows payers plenty of wiggle room, and many will use it. Some payers have much more stringent requirements. Issues will come up when individual carriers require some higher-level statement or methodology for determining the time.

The best solution for these potential conflicts is for facilities and physicians to learn what payers require, then design a record-keeping system that makes it easier for doctors to meet the standard. It would help if they had a templated system, Kottman says. If you have a space printed on the chart for critical care and call it to the doctors attention, it makes it a lot easier to document critical care time.

But while templates provide simpler record keeping, most EDs still use either dictation or handwritten charts. Kottman asserts, If the hospital isnt willing to spend money on custom charts and sticks with handwritten records, theyre going to have legal problems, theyre going to have reimbursement problems, and theyre certainly not going to be able to deal effectively with critical care.

Note: Free customized medical charts can be downloaded at FreeChart.com

Convincing Doctors to Document

Doctors already have a lot of paperwork to do, and many may not be enthusiastic about any additional record keeping. Kottman maintains, You can see the difference between $160 and $378, and its a big deal. The hospital administration will talk to the contract holders and say, Look, were losing lots of money. If you dont get your doctors to document better, you could lose your contract. Few facilities are likely to require extreme measures, but all of them should be prepared to make arrangements with their physicians regarding critical care documentation. In the past, the physician hurt only himself or herself and his her own group of doctors. Now, the hospitals are going to be adversely affected as well.

Critical Illness or Injury The Health Care Financing Administrations (HCFAs) Dec. 23 program memorandum about changes in the use of CPT codes 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes) explains that CPT 2000 has redefined critical illness or injury as a condition that acutely impairs one or more vital organ systems such that the patients survival is jeopardized. This definition has removed the term unstable, which has caused confusion among healthcare providers for years. HCFAs new definition of critical care states that the care involves 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 vital organ system failure or to prevent further deterioration. It may require extensive interpretation of multiple databases and the application of advanced technology to manage the patient. 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 described above. Critical care excludes most specific medical or surgical procedures, which should be billed separately. Procedures excluded include endotracheal intubation, CVP lines, arterial lines, chest tubes, laceration repair, reduction of fractures, and dislocation. The memorandum goes on to address many facets of critical care ranging from required locations, who can and cant perform the services, and reimbursement. The memo can be found on the World Wide Web at http://www.hcfa.gov/pubforms/transmit/b994360.htm