ED Coding and Reimbursement Alert

And watch your reimbursement rise from the ashes

If your payment for critical care services leaves something to be desired, your practice may be inaccurately reporting these services based on correctable misconceptions. Take stock of these common 99291-99292 pitfalls to make sure you-re not falling prey to critical care no-no-s.

Myth #1: Since critical care is the highest level of E/M, you need to satisfy all the E/M elements.

Reality: Actually, 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 time-based codes--and if you look carefully at the code descriptor requirements in CPT, you-ll find no specific requirements for history, physical exam and medical decision-making (MDM).

-Most of the codes in the E/M section of CPT have specific key element requirements with regard to history, physical exam, and medical decision-making,- says Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI, an ED billing company in Stoneham, Mass.

For example, to report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history, a comprehensive examination, and medical decision- making of high complexity), you need a comprehensive history, comprehensive physical exam, and high-level MDM--but those requirements aren't present for critical care, Granovsky says. -These are time-based codes that also require a high probability of imminent or life-threatening deterioration in the patient's condition.-

And that time must include at least 30 minutes of care, excluding any separately billable procedures the physician performs, such as endotracheal intubation.

Myth #2: Critical care must take place in the CCU or ICU.

Reality: While physicians usually end up treating critical care patients in the designated critical care unit (CCU) or intensive care unit (ICU), critical care can take place anywhere in the hospital, says Valrie Hall, CCS, with Peak Health Solutions. According to CPT, critical care isn't specific to any location, such as an ICU or CCU. What determines whether you can report 99291 is the patient's critical condition, Hall says.

If necessary, the physician can perform critical care on the medical-surgical floor, in an observation unit, and particularly in the emergency department, Granovsky says.

For example, the ED physician is working a clinical shift and responds to a code blue called by the radiology department. An inpatient was receiving an x-ray study, had a perforated ulcer, and went into cardiac arrest. The ED physician intubates the patient and restores her vital signs, starts her on dopamine and fluids, and gives her needed blood, all in the radiology suite.

The patient goes to surgery and ultimately goes back to the inpatient ward. The physician documents 45 minutes of critical care. Even though the ED physician performed all the services in radiology, you would report this service with 99291--but remember to indicate that the place of service was inpatient, Granovsky says.

Myth #3: The physician's time spent with critical care patients must be continuous.

Reality: The time doesn't have to be continuous, but the physician must devote the time she does document as critical care exclusively to that patient. For example, the doctor attends to the patient at the bedside and makes an assessment. The physician can count the bedside time as critical care minutes (assuming the service meets all other critical care requirements) but must stop the clock when she leaves, Granovsky says. When she later goes to radiology to look at an x-ray for that patient, the clock should be running again. If all this time adds up to 30 minutes or more, and the doctor designates critical care, you should report the appropriate codes.

Myth #4: We will get paid for 99291 and another E/M code from the same date of service.

Reality: Yes, CPT specifically allows you to report a critical care service and another E/M service on the same day by the same physician--but most payers have edits that preclude you from getting reimbursed for both.

As for Medicare, in some cases you can report both and in others you can-t. When the critical care comes first and the E/M service second, Medicare won't allow payment. But when the E/M services occur first, they may pay.

For instance, suppose a 65-year-old male undergoes a level-five evaluation for chest pain and is waiting for an inpatient bed. Two hours later, still in the ED, he suffers a Vfib arrest and the physician performs defibrillation and resuscitation, and starts the patient on a lidocaine drip. The doctor then administers 37 more minutes of care.

In the above scenario, the E/M service happened first, so you would report 99285. After a drastic change in status, the patient required critical care, which you would report with 99291. In this situation, Medicare would allow you to report both, Granovsky says.

Smart idea: Be prepared to appeal these claims with spotless documentation, Granovsky says. -Generally, these claims require a paper appeal with the medical records,- he says.

Myth #5: If two physicians simultaneously provide critical care, they can both bill for it.

Reality: Medicare allows only one provider to report critical care at the same time. According to the Part B Reference Manual from April 2002, -Only one physician may bill for a given hour of critical care, even if more than one physician is providing care to a critically ill patient.-

Example: A 65-year-old female involved in a car crash presents with a femur fracture, pneumothorax, and ruptured spleen. Both the ED attending physician and the trauma attending provide critical care at the same time to this Medicare patient. In this case, only one of the doctors could report 99291.

Whether the billing physician will be the ED doctor may depend on intra-facility agreements more than the actualities of the care. In the above case, you might have one of two scenarios: The trauma attending might bill for critical care while the ED physician bills an ED E/M, or the trauma attending might bill a consult code while the ED physician bills critical care.