ED Coding and Reimbursement Alert

When the ED physician leaves a critically ill patient's bedside to attend to another matter, that does not mean you have to permanently stop counting critical care minutes --though you do have to stop counting minutes until the critical care resumes.

"Critical care time does not need to be continuous; for example, the physician could provide 35 minutes of CC inthe morning, then 23 more in the afternoon," offers Michael Lemanski, MD, billing director at Baystate Medical Center in Springfield, Mass.

Consider this example, courtesy of Lemanski: The ED physician treats a 68-year-old woman with cirrhosis. She has a history of alcoholism and, upon presentation,she appears very pale, hypotensive, and tachycardic. The physician orders two large bore IVs so she can administer fluid boluses and get the patient crossmatched for blood.

The physician documents that she spent 67 minutes providing critical care for the patient, from 9:23 a.m. until 10:30 a.m. and confirms a diagnosis of a "GI bleed."

The patient stabilizes and is awaiting admission to the hospital. About 90 minutes later, a nurse approaches the physician and says the patient is diaphoretic and complaining of chest pain. Her blood pressure is again low and an EKG shows new changes consistent with ischemia.

Several highly complex and difficult decisions lie ahead, such as whether to administer aspirin to a patient with a GI bleed, or nitroglycerin to a patient who presented with hypotension, explains Lemanski.

The ED physician discusses the situation with the patient and her family, treats her hypotension and active chest pain, then consults with cardiology and takes the patient to the cath lab. The physician provides another 25 minutes of critical care for this encounter.

In this instance, the ED physician has now provided a total of 92 minutes of non-consecutive critical care. On the claim, report the following:

• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 74 minutes of critical care

• +99292 (... each additional 30 minutes [List separately in addition to code for primary procedure]) for the next 18 minutes of critical care

Append the following diagnosis codes to both critical care codes:

• 578.9 (Hemorrhage of gastrointestinal tract,unspecified) for the GI bleed

• 458.9 (Hypotension, unspecified) for the hypotension

• 785.0 (Tachycardia, unspecified) for the tachycardia

• 413.9 (Angina pectoris; other and unspecified angina pectoris) for the angina

• 571.2 (Alcoholic cirrhosis of liver) for the cirrhosis.