ED Coding and Reimbursement Alert

Know what to ask the doctor for improved 99291 claims
 
Coming up short when coding for critical care services (99291 and 99292)? More often than not, the culprit is insufficient documentation. Keeping exact track of time and resources expended - often difficult in your standard ED - is essential to correct critical care claims.

"We see cases that could be critical care yet can't be billed, because the time is missed or the documentation just isn't enough to support the selection of the critical care code," says Caral Edelberg, CPC, CCS-P, president, chief executive officer and founder of Medical Management Resources, a TeamHealth Company.

Know Critical Care When You See It

The first step to correctly reporting 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes) is to identify patients who are "critically ill" or "critically injured." According to CPT, "critical" illnesses and injuries are conditions that "acutely impair one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition." A critical care situation involves a physician with the highest level of preparedness intervening urgently to stop a patient's condition from becoming far worse.

Time flies when the ED physician is performing life-saving services, so check the documentation for signs of at least 30 minutes spent administering critical care services.

Remember: You can't include separately billable procedures in the time calculation. Also, the physician must attend exclusively to that patient during documented time for a service to qualify.
 
Example: A patient who presented with chest pain receives evaluation when she suddenly collapses. The ED physician quickly orders CPR and intubates. After he resuscitates the patient, he checks her medical history and obtains additional information through conversation with the patient's husband. The physician then aggressively treats the patient with intravenous nitroglycerin and lidocaine. After review of a chest x-ray for tube placement, the ED physician consults with the patient's oncologist and her family.

Total time of the encounter: 90 minutes, 60 of which were spent attending to the patient and providing critical care services after she had collapsed and after performing the two separately billable procedures (intubation and CPR).

In this instance, you would code a level-five visit (99285) since the physician performed a "comprehensive" E/M service. Report 31500 (Intubation, endotracheal, emergency procedure) and 92950 (Cardiopulmonary resuscitation) for the intubation and CPR.

You should report the 60 minutes of post-collapse treatment with 99291 and append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to this code to show that it was a separate service from the 99285. The time the physician spent providing critical care in this example was continuous, but this is not always the case. 

"There is not a requirement for continuous care. The time may be cumulative over a period of time," says Barbara Cole, BSN, RN, CPC, president of ProTech Reimbursement Services, a national firm specializing in emergency medicine professional and technical coding. "You can count time spent engaged in work directly related to the individual patient's care, whether at bedside or elsewhere on the floor or unit."

Critical care encompasses actions "in addition to the time spent by the bedside: reviewing test results, discussing the case with staff, time spent discussing the situation with the patient's family, making management decisions, and talking to other physicians," Edelberg says. But remember that the clinical activities must directly contribute to the patient's care.

"That's a real challenge, but somehow the doctor has to tell you how much time he spent with this patient," she says. "You can take the doctors' [documented] word for it; you just need to teach them what is included (in critical care) and what's not."

Smart idea: To reduce uncertainty, work with your physicians to develop a consistent critical care attestation for appropriate cases. For example, a statement such as "I delivered greater than 30 minutes of critical care outside of separately billable procedures" will satisfy the documentation requirements.

Separately Report Certain Procedures

To get paid for critical care that occurs on the same day as a separate procedure with a global fee period, you need to append modifier 25 to the critical care code.

CPR, endotracheal intubation, pericardiocentesis, central venous catheter placement, and EKG interpretations are examples of procedures that you can report separately in addition to critical care.

CPT also lists several procedures as services inclusive in critical care time: interpretation of cardiac output measurements, chest x-rays, pulse oximetry, information data stored in computers, and blood gases; gastric intubation; temporary transcutaneous pacing; ventilatory management; and certain vascular access procedures. If the physician performs any of these services, you should not report them separately from the critical care.

"If it's not listed in the inclusive services in CPT, then it can be billed separately," Edelberg says. But, "if you're going to bill [critical care], you have to add modifier 25 to the critical care code to indicate that critical care as a significant, separately identifiable procedure."