ED Coding and Reimbursement Alert

By Caral Edelberg, CPC, CCS-P
President, Medical Management Resources Inc.
Consulting Editor


Billing for critical care services in the emergency department (ED) continues to be confusing for many coders. A review of the basic differences between the Health Care Financing Administration (HCFA) and American Medical Association (AMA) policies will help clarify the issue.

Medicare Policy for Critical Care

HCFA Transmittal B-99-43, dated December 1999, explains the criteria for documentation and coding of critical care services (99291-99292) brought about by the modifications in CPT 2000.

For 2000, CPT redefines a critical illness or injury as one that acutely impairs one or more vital organ systems such that the patients survival is jeopardized. CPT no longer uses the term unstable in its definition of critically ill or injured patients.

CPT 2000 also eliminates the requirement for constant attention as a prerequisite for use of critical care codes. The new language states:

The CPT critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

The following activities may be counted toward critical care time:

Time spent with the patient should be documented in the patients record.

Physicians can claim any time engaged in work directly related to the patients care, including:
1. Reviewing test results or imaging studies.
2. Discussing the patients care with medical staff.
3. Documenting critical care services in the medical record.
4. Discussing the patients condition with family members or other decision-makers when the patient is unable to participate in the discussions, as long as the discussion bears directly on the critical care case. The rules regarding such discussions are quite complicated, and coders unfamiliar with the requirements should review them in CPT 2000. Only questions related to decision-making regarding treatment may be counted toward critical care. Telephone calls to family members and surrogate decision-makers must meet the same conditions as face-to-face meetings.

Activities that do not qualify for critical care include:

Time spent in activities that occur outside of the unit or off the floor.

Time spent in activities that do not directly contribute to the treatment of the patient even if they are performed in the critical care unit.

Family discussions involving regular or periodic updates of the patients condition, emotional support for the family and answering questions regarding the patients condition. [...]