ED Coding and Reimbursement Alert

Hint: Discharged patients may still require 99291 or +99292.

Critical care coding happens in all settings – physician offices, the intensive care unit, and importantly, the ED. And what we’ve learned at ED Coding Alert is that although these codes are familiar to emergency departments, they remain a source of confusion.

We collected the three most common questions submitted by readers and researched the answers straight from the AMA or insurers. Check out the following advice to ensure you aren’t reporting critical care visits incorrectly.

Don’t Count on ROS, HPI

Question 1:  We aren’t able to find out which levels of review of systems (ROS) and history of present illness (HPI) we must meet before we can report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). Can you advise?

Answer 1: These elements aren’t necessary in determining whether critical care is warranted, according to CPT^® guidelines. “Critical care is the direct delivery by a physician or other qualified health care professional of medical care for a critically ill or critically injured patient,” CPT^® says in its definition of the service.

Critical care is not based on any of the data elements associated with emergency department E/M levels. It’s based on time only, for the critically ill or critically injured patient, meaning there is a high probability of imminent or life-threatening deterioration of the patient’s condition.

Because critical care is a time-based code, you are excused from meeting all the usual elements with regard to HPI, physical examination (PE), past, family, and social history (PFSH), and ROS that are required for the standard ED evaluation and management codes 99281-99285. However, the chart must reflect the nature of the patient’s critical illness and that at least 30 minutes of care was spent outside of separately billable procedures.

In Some Cases, Discharge Can Occur Post-CC Service

Question 2: We recently received a chart for a patient who was in the ED for anaphylaxis so severe that the physicians performed critical care services on her. However, the patient was discharged from the ED that same day. We’ve never seen a critical care case that didn’t result in a hospital admission, so we want to make sure this is okay to report with 99291.

Answer 2:  You’re correct in noting that this situation is out of the ordinary, but it is still billable as your physicians have suggested, assuming the documentation supports the service. Just because patients require critical care services doesn’t mean they won’t improve enough to warrant discharge – in the case of an anaphylactic reaction due to allergies, it would be possible for the stabilized patient to be discharged directly from the ED.

As long as the physician’s work meets the definition of critical care, there is no requirement that he admit the patient to the hospital to report codes 99291 or +99292 (... each additional 30 minutes (list separately in addition to code for primary service)).

Common clinical scenarios for critical patients who are discharged include anaphylaxis, angioedema, asthma, and sometimes even congestive heart failure. These are just examples, however – you should not consider a service critical care based on the diagnosis. Whether a service meets critical care requirements depends on the treatment, the level of care performed, the gravity of the patient’s condition, and the physician’s documentation and notes.

Remember the exceptions: “You should not consider that the provision of care to a critically ill patient is automatically a critical care service just because the patient is critically ill or injured,” CMS says in MLN Matters article MM5993. “To this point, each physician providing critical care services to a patient during the critical care episode of an illness or injury must be managing one or more of the critical illness(es) or injury(ies) in whole, or in part.”

In other words, if the patient presents with anaphylactic shock and the ED physician administers an epinephrine shot but a cardiologist or other specialist manages the actual critical care period because of the patient’s anaphylaxis-driven arrhythmia, then it’s likely that the cardiologist’s notes would support reporting critical care and the ED physician’s may not. This is why it’s essential to read the entire medical record before selecting a code.

Can ED Physicians Report Services Outside the ED?

Question 3: Our ED code team was called to attend a code in the MRI suite, and one of our attending physicians provided critical care to a patient who was in cardiac arrest. The physician resuscitated the patient and transferred him directly to the operating room. Since the critical care took place outside the ED, can we still bill for the service?

Answer 3: Yes, you can. Where the physician performs critical care is irrelevant, as long as the care itself meets the requirements for 99291 and +99292.

“While critical care is usually given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department, payment may also be made for critical care services that you provide in any location as long as this care meets the critical care definition,” CMS states in its coverage determination for these services.

The bigger question in this case was whether your physician spent the minimum required amount of time (30 minutes) on providing critical care services. If he performed CPR but did not meet the critical care threshold, you’d report 92950 (Cardiopulmonary resuscitation [eg, in cardiac arrest]) instead of 99291.