ED Coding and Reimbursement Alert

CPT has revised the language for critical care and has increased relative value units (RVUs) for 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (... each additional 30 minutes). Coders must know what these changes mean and how they will affect coding.

My general feeling is that the definition of critical care, as it is spelled out for 2001, is considerably looser than it was for 2000, explains Michael Granovsky, MD, chief financial officer of Greater Washington Emergency Physicians, a five-physician group staffing a 24,000-visit ER in suburban Maryland. RVUs have been increased to 4.0 for 99291, and 2.0 for 99292. This is roughly a 10 percent increase over last year. In 2000, the RVUs for critical care were decreased, and this current change restores them.

According to the Federal Register, The earlier reductions to the work RVUs were made assuming there would be a substitution of use of the critical care codes for other codes that would increase net payments if there were no reductions to the work RVUs. We do not believe this substitution will occur because of additional revisions to the definition of critical care for 2001. Thus net payments would decrease if we do not restore critical care RVUs to their former levels.

Although the definition appears to be broader, and RVUs were increased, the 2001 changes are considered budget neutral (Federal Register, page 44208).

One explanation for this apparent contradiction is that although the CPT changes broaden the times when ED physicians use the critical care codes, they may limit the time when physicians outside the ED can use 99291 and 99292.

It appears to be budget positive for the ED, but it is budget neutral for the application of 99291 throughout all specialties, Granovsky explains. We are not the only users of 99291. Its for the effect on those physicians who are taking care of critical care patients outside of the ED that the code is a little tighter.

A Breakdown of the Changes

All of the changes are highlighted in the CPT 2001 book by arrows that show when new or changed language has been added. Some of the changes either qualify or clarify already accepted aspects of the critical care definition.

Five significant changes are:

1. A look at high probability.
The language: In CPT 2001 the introduction to critical care now reads, A critical illness or injury acutely impairs one or more vital organ systems such that there is a [...]