ED Coding and Reimbursement Alert

Your ED physician provides 42 minutes of critical care to a patient, but you report a level-five ED E/M instead. No big deal, right?

Wrong: The critical care code pays around $45 more per claim. Use this FAQ to grab all the green you can on potential critical care claims.

For coding purposes, a patient must be critically ill or injured in order to report critical care services. "Critically ill or injured patients have one or more vital organ systems acutely impaired, such that there is a high probability of imminent or lifethreatening deterioration in the patient's condition" if the physician does not intervene, explains Deb Williams, CPC, coding supervisor at Horizon Billing Specialists in Grand Rapids, Mich.

In short: Critical care occurs when a lack of physician intervention will quickly lead to a worsening of the patient's condition. If the physician does not intervene, the patient will only get worse very quickly -- and is at risk for rapid deterioration. The physician must spend at least 30 minutes providing critical care before you can code for it, however.

Some examples of patient conditions that might warrant critical care include, according to Williams:

• severe allergic reactions

• sepsis

• impending respiratory failure

• motor vehicle accident (MVA) patients with multiple injuries

• myocardial infarction (MI)

• alerted mental status.

However: A patient suffering from one of the listed conditions does not necessarily meet the coding requirements for critical care. The key to critical care patients is the potential for rapid deterioration without immediate physician intervention.

Several other services the physician provides to the critically ill or injured patient count toward critical care time and are not separately reportable; these services commonly include:

• interpretation of cardiac output measurements

• chest x-rays

• pulse oximetry

• blood gasses

• tests that store information digitally (for instance, blood pressures, hematologic data)

• gastric intubation

• temporary transcutaneous pacing

• ventilatory management

• vascular access procedures (not including most of the central line codes).

Physician knowledge of this coding intricacy is not a given, explains Jim Strafford CEDC, MCS-P, vice president of client services with Omega Healthcare."A major issue with critical care is a lack of understanding on the part of ED docs as to what elements can get them to 30 minutes of critical care. I spoke with an ED physician yesterday who totally misunderstood time documentation requirements for critical care," he says.

Payout: Strafford's point hits home when you look at the numbers. If you report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), you'll rein in about $216 (5.99 transitioned facility relative value units [RVUs] multiplied by the temporary Medicare conversion rate of 36.0846).

Conversely, 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 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 ...) pays about $170 (4.74 RVUs multiplied by 36.0846).

So be sure that you know what types of physician actions you can include in critical care time -- and what you cannot.

When totaling critical care minutes, you will need to deduct the time spent performing separately reportable procedures from overall critical care time, including:

• CPR

• endotrachael intubation

• chest tube/central line insertion

• ultrasound interpretation

• laceration/orthopedic repairs.

You should also deduct teaching time from critical care. Plus, you can't include time spent speaking with people other than the patient that does not directly bear on the patient's medical care.

Counts toward 99291: A patient reports to the ED in anaphylactic shock from multiple bee stings. The patient is uncommunicative, so the physician spends four minutes speaking with the patient's wife about his allergies and current medical conditions.

Does not qualify: A patient reports to the ED in anaphylactic shock from multiple bee stings. The ED physician orders blood work and several labs; while he is waiting for the labs to come back, the physician spends four minutes consoling the patient's family and updating them about the patient's condition.