ED Coding and Reimbursement Alert

Most emergency department (ED) coders are familiar with the standard scenarios in which critical care is provided: a severely injured accident victim or a patient with unstable vital signs and chest pains. But to maximize your reimbursement potential, you have to know when you can use critical care codes in some lesser-known situations, and what the physician must document before you can report critical care.
 
Many emergency care coders inadvertently come up short when coding for critical care services (99291 and 99292). The reason? Insufficient documentation. Keeping exact track of time and resources expended - often very difficult in your standard ED - is essential to correct critical care claims, says Caral Edelberg, CPC, CCS-P, president, chief executive officer and founder of Medical Management Resources, a TeamHealth Company.
 
"We see cases that could be critical care yet can't be billed, because the time is missed or the documentation just isn't enough to support the selection of the critical care code," she says.
 
So the question becomes: How can ED coders be ethically paid for critical care services without wrapping themselves up in red tape or raising the eyebrows of suspicious payers? A little knowledge will go a long way toward helping your office assess critical care services and obtain payment when they are provided.

Think You Can Identify Critical Care? Think Again

The first step to correctly reporting 99291 and 99292 is to identify patients who are "critically ill" or "critically injured." According to CPT 2003, "critical" illnesses and injuries are defined as conditions that "acutely impair one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition."
 
CPT goes on to report that "Critical care involves high-complexity decision-making to assess, manipulate and support vital system functions, to treat single or multiple vital organ system failures and/or to prevent further life-threatening deterioration." In other words, a critical care situation involves a physician with the highest level of preparedness intervening urgently to stop a patient's condition from becoming far worse.
 
As previously noted, time is also a factor in critical care coding. A minimum of 30 minutes must be spent administering critical care services for a visit to be considered critical care; separately billable procedures may not be included in the time calculation. The physician must also attend exclusively to that patient during documented time for a service to qualify.
 
For example, a patient who presented with chest pain is undergoing evaluation when she suddenly collapses. The ED physician quickly orders CPR and intubates. After the patient is resuscitated and stabilized, the physician checks her medical history and obtains additional information through conversation with the patient's husband. A chest x-ray is then reviewed for tube placement, and the ED physician consults with the patient's oncologist and her family. Total time of the encounter was 90 minutes, 60 of which were spent attending to the patient after she had collapsed and after the two separately billable procedures (intubation and CPR) had been performed.
 
In this instance, code a level-five new or established patient visit (99285) since the doctor did perform a "comprehensive" E/M service. Report 31500 (Intubation, endotracheal, emergency procedure) and 92950 (Cardiopulmonary resuscitation) for the intubation and CPR.
 
You should report the 60 minutes of postcollapse treatment with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).
 
The time the physician spent providing critical care in this example was continuous, but this is not always the case.
 
"The time requirement is not cumulative," says Barbara Cole, BSN, RN, CPC, president of ProTech Reimbursement Services, a national firm specializing in emergency medicine professional and technical coding. "You can count time spent engaged in work directly related to the individual patient's care, whether at bedside or elsewhere on the floor or unit."
 
According to Edelberg, critical care encompasses actions "in addition to the time spent by the bedside: reviewing test results, discussing the case with staff, time spent discussing the situation with the patient's family, making management decisions, and talking to other physicians." Keep in mind, however, that the clinical activities must directly contribute to the patient's care.
 
Edelberg understands the possible predicament when an ED coder considers filing a critical care claim.
 
"That's a real challenge, but somehow the doctor has to tell you how much time he spent with this patient," she says. "You can take the doctor's [documented] word for it; you just need to teach them what is included (in critical care) and what's not."
 
When coding, make sure to clearly and thoroughly document all of the time your physician spends providing
services. If the level-of-service criteria are met and the time exceeds 30 minutes, critical care has been achieved. Also, don't forget to include information from the physician documenting the visit and "make sure it's relevant" to critical care, Edelberg says.
 
"Make a note in the record that indicates that the (critical care) time is exclusive of otherwise billable procedures," she says "On audit, an auditor from Medicare would look for that note."

Separately Report Some Procedures

To get paid for critical care that occurs on the same day as a separate procedure with a global fee period, you need to append modifier -25 to the critical care code.
 
CPR, endotracheal intubation, pericardiocentesis, central venous catheter placement, and EKG interpretations are examples of procedures that can be billed separately in addition to critical care.
 
CPT also lists several procedures as services inclusive in critical care time: cardiac output measurements, chest x-rays, pulse oximetry, information data stored in computers, blood gasses, gastric intubation, temporary transcutaneous pacing, ventilatory management, and certain vascular access procedures. If any of these services are performed, you should not report them separately from the critical care.
 
"If it's not listed in the inclusive services in CPT, then it can be billed separately," Edelberg says. But, "if you're going to bill [critical care], you have to add -25 to the critical care code to indicate that critical care as a significant, separately identifiable procedure."