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 [...]