ED Coding and Reimbursement Alert

Many ED groups may be missing out on a significant amount of revenue because they are underusing the evaluation and management codes for critical care services (99291-99292).
When I talk to physicians, I ask them to estimate what percent of the care they provide is critical care, and, typically, they say 5-10 percent. But, when you look at the billing companies that specialize in emergency medicine, they usually only bill critical care about one percent of the time, observes Betty Ann Price, RN, BSN, CCS-P, president of Professional Reimbursement Strategies, a practice management and reimbursement consulting firm based in Palmetto, FL.

CPT defines critical care services as the evaluation and management of the unstable critically ill or unstable critically injured patient, requiring the constant attendance of the physician.

Treating victims of motor vehicle accidents with multiple traumatic injuries, and the management of chest pain patients who present with unstable vital signs are just two examples of care that is often provided in the emergency department which could most likely be coded as critical care services. But, because these codes are specifically based on time, which is difficult to document in the ED, most departments end up billing critical care services with the emergency department services codes (99281-99285), which are not time-specific or as profitable.

A level five E/M code for emergency services (99285) carries only 4.24 relative value units (RVUs), while critical care code 99291 is worth 5.60 RVUs, Price adds.

The key to getting adequate reimbursement for critical care, she explains, is in knowing when and how to bill for it. Providing accurate documentation that the physician performed these services, and making sure that your third-party payers recognize that this is significant portion of emergency care provided to their members, is critical.

What Is Critical Care?

Billing for critical care services is a tricky area for emergency medicine because exactly what constitutes a critical illness, injury or complication is not clearly defined in CPT, says John Turner, MD, PhD, director of documentation and coding compliance at Team Health, an emergency medicine practice group based in Knoxville, TN.
Although CPT states critical care codes should be used for the care of an unstable patient who requires the constant attendance of the physician, what is the definition of unstable?

Some patients have vital signs that are outside the norm for most people, but are normal for them. Sometimes patients may present with a seemingly minor problem, but then later require life-saving treatment.

How are ED coders supposed to know that the care provided meets the medical standard of critical care?

Turner advises his coders to first rely on the physicians notes in the patient chart.

1. Critical care is the subjective judgment of the physician. Did the physician write critical care services provided 45 minutes? Turner asks. If the physician does not say it in the chart, then I would not code it as critical care.

There are no objective hard and fast rules as to what constitutes a critical patient, he emphasizes. Whether or not critical care is provided is largely a decision made by the physician.

Some ED physicians have been known to write down critical care when the service provided didnt really constitute the definition, Turner admits. We did have a problem with some physicians billing critical care for acute bronchitis, for example, [because] they spent a lot of direct time with the patient and the condition can be serious.

But, that isnt really what constitutes critical care, in his opinion, Turner states. I would tell physicians that critical care services are the really sweaty palms cases, where you go in and look at the patient and think, Wow, this person is really, very sick; they could be dying.

2. Disposition of the patient can be supporting evidence. While Turner feels that coders should rely first and foremost on the physicians documentation, there are some additional clues in the patients chart to whether or not critical care services should be billed.
Was the patient admitted to the hospitals critical care unit or just admitted directly to a regular floor of the hospital? Was the patient discharged home?

In many cases, the disposition of the patient will be to the intensive care unit or critical care unit, he notes.
However, in some cases, a patient may be admitted to the ICU, but not have required critical care in the ED. For example, a person on lidocaine who needs monitoring, the only place to do that is in a critical care unit, he explains. But, they dont require critical care.
Conversely, a critical congestive heart failure patient may present with life-threatening complications, but respond so well to treatment in the ED that admission to the ICU is not warranted.

In this situation, the ED physician could still bill critical care because the patient presented in a critical, unstable, and life-threatening condition, he adds. Thats why you need to first have the physicians indication that the service performed was critical care.

3. Diagnosis is key, but should not be the final word. In many cases of critical care, the diagnosis listed will provide indisputable evidence that critical care should be charged.

If you have a diagnosis of pulmonary edema, or cardiogenic shock, or something like that, its pretty obvious that the physician was going to have to be constantly with the patient and directly overseeing their care, Turner states.
However, some diagnoses may not appear to be life-threatening, but the patient indeed required critical care services in the ED. Again, the coder should rely primarily on the physicians record, he states.

4. Use common sense. There are cases in which a physician will document that he or she has provided critical care, but a careful look at the nurses triage notes and the physicians initial assessment reveals inconsistences that cannot and should not be ignored, states Caral Edelberg, CPC, president of Medical Management Resources, Inc., an emergency medicine coding and reimbursement consulting firm in Jacksonville, FL.

I just finished a critical care audit for a large tertiary care facility, Edelberg notes. They sent over some charts and I found that, in several cases, the nurse had documented that the patient was alert times three, ambulatory, and had no acute signs of distress. The physician had documented in his assessment that the patient was not in distress. But, the physician billed the visit as critical care.

Such a generous interpretation of the CPT code wont sit well with Medicare auditors, both Edelberg and Turner caution.

Critical care codes are the one set of E/M codes that emergency physicians have that are strictly based on time. They dont require the documentation of the history, medical decision-making, or exam the way the other E/M codes do, Turner explains. If Medicare denies the critical care code as unsubstantiated, and the physician doesnt have the documentation to support a high-level E/M code, that visit will probably get bumped down to a level two E/M.

Codes Dont Require Constant
Bedside Attendance

CPT clearly states that critical care time includes all time spent focused on the direct care of the patient, even time the physician spends away from the patients bedside. However, many ED administrators and physicians mistakenly believe that the doctor must be in direct, face-to-face contact with the patient in order for critical care time to be charged, Price has found.

Its the phrase constant attendance in the CPT definition, that causes a lot of confusion. Many people interpret that to mean that the physician has to spend the total amount of time at the bedside, and that is not the case. It is the total time the physician spends focused on the care of that patient, she explains.

According to CPT, the physician need not be constantly at bedside per se but is engaged in physician work directly related to the individual patients care.

Amount of Time Must be Documented

The real problem for coders in this scenario, Price notes, is that although they may realize that the physician does not have to be present at the patients bedside, if the doctor doesnt clearly document the time spent focused on the care of the critical patient, the coder is often unable to piece together enough time to meet the requirements of billing 99291 (evaluation and management of the unstable critically ill or unstable critically injured patient, requiring the constant attendance of the physician; first hour).

99291 should be billed for the first hour of critical care provided, Price notes. This code can be billed if at least 30 minutes of critical care is performed. If it does not take that long to perform the service, it cannot be billed as critical care and should be billed using the emergency department services codes. For each half hour of critical care delivered beyond the first hour, 99292 should be billed. (For a guide to the time specifications used for critical care codes, see the chart below.)

The time spent focusing on the care of the patient also does not have to be continuous, Price adds. Critical care is billed for the total interval of time spent on the care of the patient. For example, the ED physician may spend 12 minutes at the bedside examining the patient, then, say, another 10 minutes reviewing the diagnostic studies, then another 10 minutes re-examining the patient, for a total of 32 minutes. They should still bill 99291 for this time, even though they might have been seeing other patients during that time period as well.

However, unless the physician scrupulously documents these small intervals of time, or unless this is evident in the nursing notes, very few coders will pick up on the fact that critical care can be billed.

Emergency physicians are very busy, and they are not always going to think to write this time down, Price continues. Short of carrying a stop watch, this care is very hard to document.

However, she counsels, it is well worth the physicians while to make sure they document critical care time in their notes. The relative value for critical care is so much higher than a level five emergency E/M code that it is really worth it.

How to Bill Critical Care Services Total Duration of Critical Care// Codes Less than 30 minutes (less than 1/2 hour)// 99232 or 99233 30-74 minutes (1/2 hr. - 1 hr. 14 min.)// 99291 x 1 75-104 minutes (1 hr. 15 min. - 1 hr. 44 min.) //99291 x 1 AND 99292 x 1 105-134 minutes (1 hr. 45 min. - 2 hr. 14 min.) //99291x 1 AND 99292 x 2 135-164 minutes (2 hr. 15 min. - 2 hr. 44 min.)// 99291x 1 AND 99292 x 3 165-194 minutes (2 hr. 45 min. - 3 hr. 14 min.)// 99291 x 1 AND 99292 x 4 Source: 1999 Physicians CPT.

Exclude Time Spent on Separate Procedures

One warning: if the ED physician performs procedures that will be billed separately from the critical care services, then the time spent on these procedures must be excluded.
Examples of the procedures are chest tube insertion, central venous catheter placement, intubation, and cardio-
pulmonary resuscitation (CPR).

For example, the time a physician spends to insert a chest tube must be deducted from the total critical care time, Price says. If a physician documents that he provided 30 minutes of critical care to a patient, but there was also a chest tube inserted during that period of time, you dont have the time you need to bill critical care.

The time must be deducted for procedures that will be billed separately because the time spent on the procedures is included in their CPT code, Price says.

However, knowing which procedures are separately billable and which are bundled into critical care is often difficult, says Connie Breedlove, director of operations for Medical Management Systems, Inc. a 40-physician emergency medicine group practice in Indianapolis, IN.

For instance, one payer may consider CPR to be bundled with critical care, while another one does not, she explains.

Note: Breedlove says her practice has developed its own policy (which adheres to Indiana Medicare requirements) on which procedures are bundled and which are separate. For our personal billing we do not treat one payer differently from another, she explains. We have certain guidelines as a group and we adhere to those. Its sort of an ongoing battle (to get some plans to pay), but thats how we do it.

Overcoming Payer Misconceptions

Many groups may not be billing critical care codes because they have difficulty getting paid, says Breedlove.
Some payers will not recognize critical care services in the emergency department. They treat the claims as though the ED is an inappropriate place of service, she says. Some payers think that only care provied in a critical care unit can be billed as critical care.

CPT specifically lists the emergency department as a correct place of service: Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, respiratory care unit, or the emergency care facility. However, Breedlove even had difficulty getting her state Medicare carrier to reimburse her physicians for critical care.

Our state medical director basically went on record saying that the ED was not an appropriate place to be performing critical care, that ED staff didnt have the right equipment and could not provide that level of care there, she recalls. I guess he thought the ambulance would come to the hospital and the doors would open up right into the ICU unit.

With the help of the state medical society and the regional HCFA representative, as well as the national American College of Emergency Physicians, they were able to change the carriers policy, Breedlove notes.

Now we are pretty much OK, although it always comes up on their edits and we have to provide documentation. Its never an autopay, she states.

Definitions Tend to Penalize Efficient EDs

Although most ED physicians provide critical care at some point, some departments are unable to use these codes because of the time constraints, Price concludes.

There are some departments that have policies to get the patient out of the ED within 30 minutes, either admitted to a unit, transferred or treated and released, she says. What do you do then? Well, you cant bill critical care. In those cases, it is likely that the patient encounter would qualify for a level five ED evaluation and management code, invoking the caveat. (See corresponding story on the ED acuity caveat below.)