ED Coding and Reimbursement Alert

 Discharged patients may still require 99291 and 99292

Think you can't report critical care codes when the doctor discharges the patient later that day? You might be surprised. Take a look at these critical care situations to determine whether you're reporting these complicated codes correctly.
 
Question #1: Are there specific guidelines that state a physician must have a certain amount of HPI and ROS in order to bill critical care time? For example, our doctor documented the physical examination and that he spent 30 minutes with the patient, but I'm not sure whether I can report 99291.
 
Answer: No, you don't actually need all of the elements of the patient's history of present illness (HPI) and review of systems (ROS) to report critical care codes when the physician has documented critical care time. "Critical care is not based on any of the data elements associated with emergency department E/M levels," says Sharon Clement, CPC, business manager of the ED physician group at Norwalk Hospital in Norwalk, Conn. "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, she says.
 
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 30 minutes of care was spent outside of separately billable procedures.
 
Question #2: Recently our practice has seen some of our attending physicians documenting that they've performed critical care services for patients whom they discharged from the ED. Is that possible? Would patients who need critical care services improve enough to go home instead of into the hospital?
 
Answer: Though such a situation is unusual, just because patients require critical care services doesn't mean they won't improve enough to warrant the physician's discharge. For example, a patient having an anaphylactic reaction due to allergies may present in the ED, receive critical care from the ED physician, and, once stabilized, safely return home.
 
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 (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]), says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City.
 
Common clinical scenarios for critical patients who are discharged include anaphylaxis, angioedema, asthma, SVT, and sometimes even congestive heart failure.
 
Remember: Don't 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.
 
Question #3: Our ED code team was called to 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: Yes, you can. Where the physician performs critical care is irrelevant, as long as the care itself meets the requirements for 99291 and 99292.
 
According to the description of critical care services in CPT, "critical care is not specific to a location, such as an intensive care unit (ICU) or critical care unit (CCU). Rather, it is determined by the patient's critical condition requiring this type of physician care." However, remember that if the physician was overseeing CPR, you must subtract out this separately billable procedure when reporting 92950 (Cardiopulmonary resuscitation) along with critical care codes.