ED Coding and Reimbursement Alert

Question: We disagree with our emergency physician's documented level of care for one of his critical care patients. The physician documented critical-care-time minutes, but upon review of the medical record, we don't think the patient's condition warrants this level of care or meets the requirements for administering critical care. We want to code the report as a level-five ED E/M service. Any suggestions as to whether we can, or should, code for a different service than the physician reported? Pennsylvania Subscriber
  Answer: If you question the necessity or length of the critical care time your physician provided, you should probably review the patient record with the physician. You should then code according to the reviewed decision. Before you send out the claim, document somewhere on it that the chart was reviewed by the physician. Before you go into the review with your physician, make sure you know exactly why you want to downcode to the level-five ED E/M (99285). Check on your critical care guidelines. The language in this section of the CPT manual has changed over the past few years. Remember, a patient's condition warrants critical care even if the danger isn't life-threatening to the patient's health. The guidelines state that a critical illness or injury is one that "acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration" (emphasis added). So, even if your patient isn't in the midst of a life-threatening situation but the possibility is likely, your physician may need to provide critical care. Check the guidelines for other details, including critical care time and other services provided during that time. For more on critical care, see the December 2002 Ed Coding Alert article "Are You Underplaying the Critical Care Codes?"