Get Physician Signoff on Critical Care Claims
Question: I am having trouble with the guidelines for critical care codes 99291 and +99292. How do we know if a patient qualifies for critical care, and how do I document the critical care on the claim? AAPC Forum Subscriber Answer: You have to get critical care claims right, because these high-paying codes are always under scrutiny by payers. The rules for 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)) are different than other evaluation and management (E/M) codes you’ll use in the emergency department (ED), but they’re also fairly clear. Before you consider 99291/+99292, you need to make sure that the physician is treating a patient with a critical illness or injury. Per CPT®, “A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” The physician should explicitly state that they provided critical care in the notes. If you don’t see critical care spelled out in the notes, pause and check with providers before considering critical care. Once it is established that the patient has a critical illness or injury, you have to be sure that the ED physician’s care meets the critical care criteria. “Critical care involves high complexity medical decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition,” CPT® reports. When the encounter meets both of the above parameters, the physician has provided critical care — but that doesn’t necessarily mean that you can automatically use 99291/+99292. Why? First, you can only report critical care codes if the provider meets the 30-minute mark. Even if the provider performs critical care, you cannot report 99291/+99292 unless the critical care lasts at least 30 minutes. If the critical care is less than 30 minutes, you’ll report 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) instead. Also, you need to be sure the time component is accurately documented for 99291/+99292 claims. The notes should include an attestation concerning critical care from the performing physician, such as “provided 36 min crit care.” Chris Boucher, MS, CPC, Senior Development Editor, AAPC
