ED Coding and Reimbursement Alert

Emergency department (ED) physicians must provide careful documentation of the critical care services they provide if they expect to see adequate reimbursement. In the wake of CPT 2000s expanded definition of what constitutes provision of critical care, the Health Care Financing Administration (HCFA) reduced the number of relative value units (RVUs) assigned to these codes (99291-99292) in their 2000 physician fee schedule. (See the insert, HCFA Update, included with the November 1999 ED Coding Alert.)

Medicare obviously thinks critical care will be utilized to a greater degree with the new guidelines. That is why they have decreased the RVUs, explains John Turner, MD, FACEP, medical director for coding and documentation at the Knoxville, Tenn.-based TeamHealth, Inc., an emergency physician staffing firm. They are worried about a significant increase in utilization of code 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and probably will be more diligent in their review of critical care charges.

HCFA Clarifies Critical Care Services to Carriers

A carrier memorandum sent by HCFA to its contracted Medicare carriers, dated December 1999 (Transmittal No. B-99-43), contains several items that may make it easier for ED physicians to get paid when submitting critical care codes.

The memo says that the patient no longer is required to be unstable in order for the services to be deemed critical care. CPT has redefined a critical illness or injury as follows: A critical illness or injury acutely impairs one or more vital organ systems such that the patients survival is jeopardized. Please note that the term unstable is no longer used in the definition to describe critically ill or injured patients.

This clarification should assist physicians in reporting critical care, Turner says. There are many instances where the patients vital signs do not truly reflect the severity of the patients condition, he says. Therefore, the ability to indicate that the patient needed the critical care services to prevent deterioration into a unstable state is very helpful.

Condition and Treatment Criteria for Critical Care

In keeping with the new CPT definition of critical care, the HCFA document indicates thatin order for critical care services to be reported to Medicarethe services have to meet specific clinical condition and treatment criteria.

In order to reliably and consistently determine that delivery of critical care services rather than other evaluation and management services is medically necessary, both of the following medical review criteria must be met in addition to the CPT definitions, the memo states. The criteria are:

Clinical condition: There is a high probability of a sudden, clinically significant or life-threatening deterioration in the patients condition, which requires the highest level of physician preparedness to intervene.

Treatment: Critical care services require direct personal management by the physician. They are life- and organ-supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration in the patients condition.

Claims for critical care that do not meet the above criteria should be downcoded to a regular emergency service evaluation and management level.

What Medicare is Looking for to Justify 99291

To ward off denials, ED physicians must specifically document not only the time spent performing critical care, but what necessitated the performance of the critical care services vs. normal ED evaluation and management services, Turner says. Physicians need to be quite specific in their documentation beyond making the statement that the visit was critical care and listing the time involved. I think the physicians should record in their chart the reason they felt the visit warranted a 99291.

Documentation should leave no doubt that the patient required that physicians full attention during the time specified as critical care, Turner says. It would be helpful if the physician noted his or her concerns in the body of the chart.

Turner gives an example of a patient with congestive heart failure (CHF): The physicians notes could specify, Patient's respiratory rate was decreasing and he was becoming tired and more obtunded, making me concerned about possible need for intubation. Or, in a patient with exacerbation of chronic obstructive pulmonary disease (COPD) and underlying end-stage cancer: Patients status was deteriorating and I needed to have extensive discussions with the family and family physician in order to determine the acceptability for intubation and ventilator support.

Physicians need to indicate in the body of the chart exactly why the patient needed their attention for the period noted. Otherwise, the charge may be denied, even if the physician notes the time spent and states that the service performed was critical care, Turner says.

Note: For more information on coding and documenting critical care services, see the article Improve Utilization of Critical Care Codes to Increase Reimbursement for Emergency Services, on page 1 of the January 1999 ED Coding Alert and the article Use Modifier -25 to Get Paid for an Emergency E/M Service and a Procedure on page 9 of the February 1999 ED Coding Alert.

Check Diagnosis Codes for Medical Necessity

Even though the HCFA memo restricts the definition of a critical illness or injury to one that offers a high probability of sudden, clinically significant or life-threatening deterioration in the patients condition, many carriers have lists of specific diagnoses that are eligible for critical care.

Our Medicare carrier maintains a list of covered ICD-9 codes for critical care and will not pay for those codes unless they are linked to a covered diagnosis, advises Donna Stevenson, billing manager for Piedmont Emergency Medicine Associates in Charlotte, N.C.

Stevenson reminds the physicians to be specific when indicating the reason the patient needed critical care, so coders can apply an appropriate ICD-9 code.

We have had to recode a bunch of claims and downcode them to either (emergency service) level fives (99285) or level fours (99284) because there was not an appropriate diagnosis, she says. We cannot send it back to the doctor and say, Can you change this to acute respiratory distress? Because respiratory distress is not a covered diagnosis. We just have to downcode it. Stevenson advises managers and physicians to check with their Medicare carriers before submitting the critical codes.

Subtract Time Spent on Separate Procedures

The HCFA memorandum also re-emphasizes that certain procedures should be reported separately from the critical care codes and should be paid separately.

Prior to 1993, the CPT definition of critical care bundled a number of fairly significant procedures into the critical care codes, including endotracheal intubation and placement of catheters, the memorandum states. At that time, it would have been consistent with the CPT definition for carriers to deny payment for those procedures when they were billed on the same date as critical care codes. However, in 1993, when the CPT definition was revised, we assigned relative value units to the critical care codes that were consistent with the revised definition.

Services such as endotracheal intubation (31500) and the insertion and placement of a flow-directed catheter (e.g., a Swan-Ganz catheter, 93503) are not bundled into the overall critical care service. These codes can be reported separately with a -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached.

The memo makes it clear that the time spent on separately reportable procedures must be deducted from the overall time counted toward billing critical care. And the memo stipulates that the physicians note must indicate that the time spent on separate procedures was deducted from the critical care time.

It will be difficult for physicians to keep in the back of their mind the times required for all the separate billable procedures in order to subtract them from the critical care time, warns Turner. It will require a great deal of discussion between the coding staff and the physicians. Some policies will have to be set and average times calculated to assist both the physicians and the coders in this area.

Certain separately billable procedures, such as cardiopulmonary resuscitation (CPR), are more easily calculated because the nursing staff records the specific times involved (i.e., time started and time stopped), he says. Other procedures, such as intubation, take a very short time and are easily subtracted. But some procedures, such as central line placement, can take a variable amount of time and be more difficult to separate, he explains.

Only through recognition of the necessity of noting the time (during the performance of the procedure) can the final times be accurately recorded. It may be that unless the chart specifically records the time required for these other separately billable procedures, it is not possible to charge them separately, he states. The physician should make some statement in the chart that the critical care time indicated did not include the time required for the separately billable procedures.

The memo also indicates procedures and codes that are bundled into the critical care service and cannot be reported in addition to critical care. (See box on page 20 for a list of codes bundled into critical care.)