ED Coding and Reimbursement Alert

Code interactions with caregiver separately -- provided the physician directly discusses treatment options.

Experts remind us that sometimes, you can count discussions with the patient's family, caregiver, or authorities toward overall critical care time. When you do, however, you'd better be sure it's wellnoted in the medical record, or you can expect payer scrutiny.

"Time spent obtaining history or discussing the patient's treatment options is not considered a separate service and should be included in the physician's total critical care time," relays Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

Example: A patient presents in apparent acute allergic reaction closing her airway; she is unable to speak or provide a history. After initial stabilization attempts start, the EP asks family members about known  allergies or exposure to substances that might have triggered the reaction. The conversation bears directly on the patient's management -- helping to clarify that this is likely an allergic reaction rather than some other cardiovascular event. After the family discussion, the EP immediately returns to the patient's bedside.

Any other discussions about the patient with family, authorities, or caregivers are not part of the critical care package.

Example: The physician takes five minutes to give a critically ill patient's wife an update; you cannot count this when totaling minutes for 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

You should also be prepared to submit specific documentation when including discussions with family/ authorities as part of critical care.

For such family discussions, Contreras recommends that the physician document:

• the medically necessary treatment decisions that made the discussions necessary

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

• a summary that supports the medical necessity of the discussion (for instance "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").

Further, "telephone calls to family members and/or surrogate decision makers may be counted toward critical care time, if they meet the same criteria" as face-to-face interactions, explains Contreras.

Best bet: Insurers may have different interpretations of how to count time your physician spends speaking to  family/authorities during critical care time. Check your payer contracts if you are unsure about an insurer's policy on critical care time.