ED Coding and Reimbursement Alert

Question: I have heard that nonphysician practitioners (NPP) in the ED can provide critical care services. I just started coding, and did not know NPPs could report 99291. Are there any special guidelines to observe when an NPP provides critical care?

Montana Subscriber

Answer: You-ll have to follow specific reporting rules when an NPP provides part or all of a critical care service or the service could end in denial.

Medicare Transmittal 1530 groups all the NPP critical care information into one place for easy reference, confirms Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Check out these basic facts on NPPs that provide critical care, and be sure to reference Transmittal 1530 (http://www.cms.hhs.gov/Transmittals/downloads/R1530CP.pdf) for any of your critical care coding questions.

(For more information on shared visit coding, see "Meet These Rules to Code for NPP Assisting MD on Shared Visit Encounters" in ED Coding Alert 2008 Vol.11, No. 9 .)

Here's a quick rundown of the most important rules to remember when coding critical care your NPP provides:

Meet scope of practice rules: An NPP can provide critical care on her own if the service meets the NPP's necessary state scope of practice and licensure requirements, according to transmittal 1530. "Collaboration, physician supervision and billing requirements must also be met," the transmittal states. A physician assistant (PA) shall meet the general physician supervis-ion requirements.

When qualified NPPs provide critical care, you can report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 ( - each additional 30 minutes [List separately in addition to code for primary service]) for their services.

Provided an NPP is properly qualified and licensed, she can provide any type of critical care a physician does. The services must meet Medicare's critical care definition.

Critical illness/injury a must: According to the transmittal, patients requiring critical care are suffering from a "critical illness or injury [that] acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition."

Examples of conditions that could acutely impair a vital organ system include:

- central nervous system failure

- circulatory failure

- shock

- renal, hepatic, metabolic, respiratory failure.

In addition, the NPP must perform high-complexity medical decision making (MDM) in order to code 99291. During this MDM, the NPP must assess the patient's deterioration potential, perform services to prevent deterioration and provide support if the patient's condition gets worse.

Coding: If the NPP provides the critical care service, then you must bill the service under the NPP's National Provider Identifier (NPI). You can never report critical care as a shared or split service -- even when the NPP and physician team up to provide critical care, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

"Unlike other E/M services where a split/shared service is allowed, the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified NPP," according to the transmittal.

Critical care is treatment provided "by an individual physician or qualified NPP and shall not be representative of a combined service between the physician and NPP," the transmittal states.