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 high probability of imminent or life-threatening deterioration in the patients condition. This has changed from 2000 when it read, A critical illness or injury acutely impairs one or more vital organs such that the patients survival is jeopardized.

Analysis: In 1999 the word unstable defined the criteria for determining whether a patient could be coded as critical care. In 2000 the definition says, Survival is jeopardized. According to this wording, the patient wasnt necessarily unstable, but might become unstable.

Now in 2001 you dont even have to have survival jeopardized, you just have to have a high probability of survival being jeopardized, Granovsky says. For example, previously you had to be having a heart attack, and getting thrombolytics, and be on your way to the cath lab to qualify for critical care.

According to John Turner, MD, PhD, medical director for documentation and coding of healthcare financial services at TeamHealth, an ED staffing firm in Knoxville, Tenn., an example of critical care pertaining to the 2001 wording would be a patient who presents with acute shortness of breath and on examination is found to be in severe congestive heart failure.

In this case, the patients vital signs may not demonstrate gross instability, but the patients work of breathing and level of consciousness may indicate a probability of rapid deterioration, Turner says. The physician would be concerned with the patients respiratory status deteriorating such that he would need intubation and would require the physicians constant attendance to prepare for that need and to continuously evaluate the treatments. You have a patient where the respiratory rate may be absolutely normal, but the reason it is normal is because the patient is so tired he cant breath.

Five minutes before he came in he may have been breathing at 40 times a minute, but now he is so tired he is breathing at a normal rate. This means he is just getting worse, Turner explains.

I think you will find a lot more ED patients fit into this concept of a high probability of imminent or life-threatening deteriorations, Granovsky says. I view it as a favorable change for application in the ED.

But favorable changes in reimbursement usually mean that a closer eye will be kept on billing and that HCFA will take a closer look to make sure it is not being abused. I think every time they make a change they watch things carefully, Granovsky adds.

Note: Payer medical review staff does not always adopt changes in CPT immediately. This makes denial followup much more important because you may have to appeal.

2. Advanced technology and multiple physiologic parameters: a clarification.
The language: Definition in CPT 2001: Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life-threatening situations when these elements are not present.

Analysis: In 2000 the wording included it may require advanced technology or multiple physiologic parameters. In 2001 critical care may be provided when these elements are not present.

I think it solidifies that you dont absolutely have to be using advanced technology or multiple physiologic parameters to qualify for critical care, Granovsky says. For example, you dont need to be having a Swan-Gans catheter and invasive arterial pressure monitoring with an arterial line to qualify for critical care. I think thats generally been peoples practice, but now its clear that it is not required.

3. Both the illness and/or injury and treatment.
The language: The following was added in CPT 2001: Providing medical care to a critically ill, injured, or postoperative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

Analysis: The key change here is that the treatment being provided must meet critical care requirements. Frequently, you will have a critical care patient in the ICU who is being seen by a consultant, but really the care that they are giving during that interaction is routine care, Granovsky says. Those docs have, in the past, been using critical care codes for more routine care that is delivered in the ICU setting. The code has been tightened for them. It will have a big impact on an infectious disease consultant who comes in and changes antibiotics. They will probably no longer be able to bill 99291.

This is because the statement says that both illness and treatment have to support the provision of critical care. My feeling is that statement will have one of the biggest impacts in the use of critical care codes throughout all specialties, he explains. But not in the ED.

Most of the time in the ED, when that 99291 is being coded, it is usually treatment-driven, Granovsky says. Its always easy in the acute setting to have severe and aggressive treatment being used. But once a patient is stabilized, those things are sort of more routine care.

ED physicians need to ensure that they are supporting the illness and injury aspect of critical care through use of the appropriate ICD-9 code. Granovsky cites an example in which a claim for critical care was submitted with an ICD-9 code for extremity pain (729.5). In fact, the patient had gangrene of the leg, which caused muscle breakdown, kidney failure, elevated potassium and abnormal EKG rhythm. The patient had to be rushed to the operating room for amputation. It was a critical care situation, but it was denied because of the use of the extremity pain ICD-9 code. The correct coding for this scenario should have been kidney failure, 584.9; elevated potassium, 276.7; abnormal EKG, 794.31; and gangrene, 785.4; in that order. Critical care is specifically described as treatment for body system failure, and that should be listed first, then list the other problems and underlying conditions, explains Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

4. Critical care and another E/M on the same day.
The language: The following was added for CPT 2001: Critical care and other evaluation (E/M) services may be provided to the same patient on the same date by the same physician.

Analysis: Previously, CPT had allowed an E/M code, usually 99285, to be submitted with 99291 under limited circumstances. Code 99291 is an E/M code, and CPT rules usually prohibit submission of more than one E/M code per encounter.

Occasionally, groups have submitted both (99291 and another E/M) and won on lengthy appeal, Granovsky says. But clearly, now Medicare is making a shift and is going to accept the use of 99291 with an E/M code, but there really have to be some extenuating circumstances.

Scenario: The patient is a 50-year-old man who comes in with chest pain. The physician does a history, physical exam, an EKG and gives the patient an aspirin as an antiplatelet agent and some nitro paste. He writes the order at 10 a.m. and checks off a 99285 (emergency department visit for the evaluation and management of a patient). There is nothing to qualify for critical care, and if the chart is done in real time, the chart is already coded. The patient is now waiting for a regular telemetry bed to become available.

He is sitting in the ED waiting to go upstairs, and all of a sudden he goes into ventricular fibrillation (V-Fib) and gets shocked, and a repeat EKG shows that he is having a massive MI with ST elevation, is hemodynamically unstable, gets TPA, codes and ends up on a Dopamine drip, Granovsky says.

From the time the patient goes into V-Fib, if 30 minutes of critical care is delivered, it is very reasonable to add 99291 on top of the 99285. The door is open to do that, and it is very legitimate, he explains.

5. Time spent with family.
The language: CPT 2001: You can report time spent with family members getting a patients history, reviewing the patients condition or discussing treatment as critical care if it bears directly on the management of the patient. The 2000 revision states if it bears directly on the medical decision-making.

Analysis: This is an area that has been abused in the past, and this is probably an appropriate tightening (of the language), Granovsky says. In 2000, family interaction had to bear on the medical decision-making, and any information can be relevant to the medical decision- making. Most elements of the history can alter your medical decision-making, but rarely would they alter your actual management.

An example of something that would alter your management is if you talk to the family and they tell you the patient has an allergy to penicillin. That changes the antibiotic you are going to give.

The single most important element of coding for critical care is still the documentation of time. For more information on this topic, please see the November 2000 ED Coding Alert Rules for Determining Critical Care on the Basis of Time, page 85.