ED Coding and Reimbursement Alert

Strategies get you ready for auditors’ critiques. 

Critical care coding is often the target of payer audits -- and mistakes can cost you.  Because the critical care codes are unlike the other E/M codes in documentation requirements, these can be misunderstood by ED coders unfamiliar with the rules that do apply. Check out these tips on what “critical” actually means and which services are, and are not, bundled into the critical care codes.

When Do Insurers Consider A Patient To Be Critically Injured or Ill? 

Insurers need a clear clinical indication that the patient meets critical care criteria. Your providers must identify and provide supporting documentation that their patient is critically ill or injured to report 99291 (Critical care, evaluation and management of the critically ill or injured patient; first 30-74 minutes) or +99292 (… each additional 30 minutes [List separately in addition to code for primary service]), reports Rebecca Parker, MD, FACEP, President of Team Parker LLC, an ED  coding and billing consulting company and Chair of the Board of Directors of the American College of Emergency Physicians.

CPT® defines critically ill or injured as “an injury or illness that acutely impairs one or more vital organ systems such that there is high probability of imminent or life threatening deterioration in the patient’s condition,” Parker explains. 

In educating our providers, we emphasize they must answer yes to these three questions, emphasizes Parker:

1. Is at least one vital organ system impaired?

2. Is there a high probability of imminent, life-threatening deterioration?

3. Did you intervene to prevent further deterioration of the patient’s condition?

In addition, the provider must document that they provided at least 30 minutes of critical care services, says Parker.

She offers these examples of patients that insurers would consider critically ill or injured:

• An acute GI bleed patient requiring emergent GI consultation and close monitoring;
• A congestive heart failure patient requiring diuretics, nitroglycerin drip and bipap for airway support; and
• Unstable vital signs, severe acidosis, severe dyspnea, or a hypertensive crisis.

Pay Attention to the “High Probability” Clause

Although most critical patients in the emergency department will be actively critically ill or injured, some may just be unstable to the point that they will very likely become critical without immediate treatment. 

When determining whether or not a patient is critically ill or injured, the physician should consider the likelihood that they would have a clinically significant deterioration if nothing was done in the next hour. 

If the probability for imminent or life threatening deterioration is high, critical care may still be appropriate to report the service.  For example, consider an asthma patient requiring multiple treatments, close observation, and third line agents such as magnesium to avoid intubation, says Parker.

Where Can the Physician Provide Critical Care?

Place of service is not restricted in CPT® other than to identify typical areas of a facility where it may occur. 

While most critical care will occur in a critical care area (ICU, ED, etc.), the physician can provide 99291 services anywhere the patient requires it. In fact, according to the Medicare database, about twenty five percent of all critical care services were provided in the emergency department setting, Parker explains.

Don’t Forget The Services That Are Bundled into 99291 and +99292

The CPT® critical care preamble includes a specific list of services that are bundled in to code 99291 and should not be reported separately. These include:

• The interpretation of cardiac output measurements (93561, 93562);
• Pulse oximetry (94760, 94761, 94762);
• Chest x-rays, professional component (71010, 71015, 71020);
• Blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data (99090);
• Gastric intubation (43752, 43753);
• Transcutaneous pacing (92953);
• Ventilator management (94002-94004, 94660, 94662); and
• Peripheral vascular access procedures (36000, 36410, 36415, 36591, 36600).

Best bet: When your physician provides any of the above services during a critical care session, do not report them separately.

Non-bundles: However, you can report the below services separately from 99291 and +99292, as they are not bundled into critical care:

• CPR (92950);
• Endotracheal intubation (31500);
• Tube thoracostomy (32551);
• EKG interpretations (93010, 93042); and
• Central venous catheter placement (36555, 36556).

Consider this example: A patient presents to the ED with worsening shortness of breath and fever. The physician examines the patient and finds him to be tachypneic, tachycardic. After a trial of bipap the patient is intubated, given antibiotics. Labs, chest x-ray, and an EKG are ordered. Multiple re-evaluations are performed prior to intubation and post intubation. The physician interprets both the x-ray and EKG, confirms ET tube placement, and the patient is diagnosed with pneumonia and sepsis. The EKG interpretation takes the physician four minutes, intubation 5 minutes and the rest of the encounter took 80 minutes.

In this example, the physician spent 80 minutes providing critical care services to this patient (this time excludes time spent interpreting the EKG). On the claim you would:

• report 99291, 99292 for the 80 minutes of critical care.
• report 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for the EKG. 
• report 31500 for the endotracheal intubation
• link ICD-9 codes 995.91 (Sepsis),  038.9 (Unspecified septicemia) and 486 (Pneumonia, organism  unspecified) to 99291 to 99291, 99292 and 93010 to prove medical necessity for the services.

 For ICD-10, the codes would be A41.9 (Sepsis, unspecified organism), and J18.9 (Pneumonia, unspecified organism)

On this claim, you would not code the chest x-ray interpretation, as it is included in the critical care code, or CPAP as it is included in ventilator management code 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management), says Parker.     

Watch this: Be sure to deduct the time spent providing these separately billable procedures from your critical care time reported, warns Parker.

Is It 30 or 31 Minutes to Qualify For Critical Care?

The 2015 CPT® book introduction discusses  time threshold requirements for code sets that contain a time basis for code selection, as follows:  “The following standards shall apply to time measurement, unless there are code or code-range-specific instructions in guidelines, parenthetical instructions, or code descriptors to the contrary. A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes). A second hour is attained when a total of 91 minutes have elapsed.” 

In the case of code 99291, there is specific language in CPT® that states 30 minutes both in the code descriptor itself and in the time threshold chart in the critical care section preamble. So for 99291, CPT® describes a threshold of at least 30 minutes, when the midpoint would have been passed, Parker explains.

Use This Time Threshold Calculator

Check With Payers Before Submitting Claims With Both ED E/M and Critical Care 

CPT® is clear in stating that critical care and other E/M services may be provided to the same patient on the same date by the same physician. However Medicare does not agree with that policy, says Parker.

In its Transmittal 1548, CMS specifically addresses this question with regard to the emergency department.  It states that when critical care services are required upon arrival into the emergency department, only critical care codes (99291-99292) may be reported.  An emergency department E/M code (99281-99285) may not be reported in addition to those services.

Important: It does not matter if the critical care precedes or follows what would normally be an E/M service in the emergency department. Transmittal 1548 clearly states that hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician (which includes any physician of the same specialty in the same group) to the same patient.

So, if a Medicare patient presents to the emergency department and receives a Level 5 ED E/M workup, and later in the shift unexpectedly clinically deteriorates requiring critical care services, according to CMS, the “same” ED physician would typically report only the critical care service -- but not both, Parker explains.