ED Coding and Reimbursement Alert

1 CMS transmittal tough on the ED, but another clears up family counseling rules

CMS has released a flurry of transmittals regarding critical care in the past months: 1473 on April 1, 1530 on June 6, 1545 on June 27 and now 1548, released July 9. The latest states that you cannot report critical care and an ED E/M by the same physician on the same date for the same patient.

We checked with the experts on this latest addition to the transmittal tangle; here's what they had to say about how it will affect your ED.

99291 Is the E/M Reporting Exception

The rub: Medicare makes an allowance for reporting critical care in association with other E/M services, such as inpatient (99221-99223) or outpatient office (99201-99215), but does not make an allowance for reporting 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) with the 9928X ED service codes, states Michael Granovsky, MD, CPC, president of MRSI, an ED coding and billing company in Woburn, Mass.

According to transmittal 1548: "Contractor shall instruct physicians and qualified NPPs that hospital ED services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient."

Also, from Section H on page 20 of Transmittal 1548:

"When critical care services are provided on a date where an inpatient hospital or office/outpatient evaluation and management service was furnished earlier on the same date at which time the patient did not require critical care, both the critical care and the previous evaluation and management service may be paid. Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient."

ACEP Questions Critical Care Exclusion

"We have been offered no explanation as to why the ED is singled out for this special exclusion," states Granovsky. The American College of Emergency Physicians (ACEP) is making a formal inquiry, he notes.

Previously, Medicare would pay for critical care following an ED E/M service, but not for an ED E/M service following critical care. (CPT allows billing both without restriction as to the order delivered.)

Check Out CMS- New Critical Care Resource

To capture valuable critical care time each time the ED physician provides it, coders need to spot critical care indicators -- and doctors need to be diligent about documenting encounter specifics.

Transmittal 1530 (http://www.cms.hhs.gov/Transmittals/downloads/R1530CP.pdf) helps providers with this process. This document puts all critical care coding guidance in one easy-to-access place, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

The transmittal, effective July 7, makes especially clear points on documenting family counseling time and coding for concurrent critical care. Keep it handy when you-re coding for 99291 and +99292 (- each additional 30 minutes [List separately in addition to code for pri-mary service]).

Adhere to Approved -Counseling- Activities

The transmittal spells out exactly what interactions with the patient's family you can count toward overall critical care time, confirms Pohlig.

According to the transmittal, "CPT codes 99291 and 99292 include pre- and post-service work. Routine daily updates or reports to family members and/or surrogates are considered part of this (included) service."

So if the physician meets for three minutes with a patient's wife to give her an update, you cannot count this as critical care time.

Exception: When the patient is unable or too cognitively impaired to give a medical history or make treatment decisions, you can count time spent consulting the family toward critical care. You can also include time spent discussing treatment decisions, for example the physician asking a family member about any allergies to certain medications.

In short: "If the physician spends time with the family for the sake of the patient, it counts toward critical care time. But if the family time is for the sake of the family, it is not critical care," explains Joan Gilhooly CPC, CHCC, president of Medical Business Resources LLC, in Deer Park, Ill.

"Critical care needs to be for the good of the patient, not the good of the family," she says.

Compare two interactions "Good morning, Mrs. Jones. Your husband slept through the night and appears to be stabilizing," does not count toward critical care time. "Good morning, Mrs. Jones. Your husband is under sedation now, but we need to give him an antibiotic. Is he allergic to penicillin or any other antibiotic?" does count toward critical care time.

You-ll need to be sure to document the family counseling time properly, Pohlig warns. When recording family counseling time for critical care, transmittal 1530 states that the provider must document four items:

- that "the patient is unable or incompetent to participate in giving history and/or making treatment decisions

- the necessity to have the discussion (e.g., -no other source was available to obtain a history- or -because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family-

- medically necessary treatment decisions for which the discussion was needed

- a summary in the medical record that supports the medical necessity of the discussion."

You cannot count any interactions with family members that do not meet the above criteria, warns Catherine Brink CMM, CPC, CMSCS, president of Healthcare Resource Management in Spring Lake, N.J.

"All other family discussions, no matter how lengthy, may not be counted toward critical care," the transmittal states. "Telephone calls to family members or surrogate decision-makers may be counted toward critical care time" -- provided the interactions meet the same criteria as face-to-face family counseling encounters.

Show Physicians the Value of Documentation

The physician also needs to be diligent about documenting the other critical care components; often, the physician does not provide enough information in progress notes to justify critical care coding.

"Critical care is commonly performed but underreported. I believe many (physicians) often miss critical care coding opportunities," says Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla.

Bottom line: To report 99291, the physician needs to spend a minimum of 30 minutes providing critical care to a patient with a critical illness or injury. If the physician performs activities that count toward that time, but does not include them in the documented time, then it's virtually impossible to capture it appropriately.

"Some physicians I talk to say they don't know what's included in critical care, which makes counting up the time very difficult for coders," said Edelberg during a recent audioconference on documenting hospital services (http://www.audioeducator.com).

Key: Documentation must support that critical care services were medically necessary and reasonable. You can report critical care services for the time the physician spent evaluating, providing care and managing the critically ill or injured patient's care. The physician must spend the time at the immediate bedside or elsewhere on the floor or unit, provided the physician is immediately available to the patient.

Don't miss: For any given period of time spent providing critical care services, the physician must devote his full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

What's not included is also important. CPR, chest tubes, wound repair, etc. are separately billable when you provide them and critical care. "It's important the physician and coders understand what -separately billable- means so that the critical care time that is documented is accurate and includes/excludes services correctly," explains Edelberg.

(For a list of procedures that are included in critical care, check out the explanation in CPT 2008 under the "Critical Care Services" subhead.)