EM Coding Alert

Hint: guidelines, bundling, and times key to clean critical care claims.

Even if you’re an experienced E/M coder, chances are you still have lots of questions regarding the correct way to use critical care codes. Understanding what constitutes critical care, what services are bundled into that care, and the correct way to document time for the service can sometimes seem overwhelming.

So, we put together four of the most frequently asked questions coders have about reporting critical care and answered them to help keep you in line with CPT^® and payer guidelines.

Turn to 99291 and +99292 For Critical Care

FAQ 1: What codes do we have to choose from when it comes to critical care?

Answer: For E/M critical care, you may report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and, if needed, +99292 (… each additional 30 minutes (List separately in addition to code for primary service)).

Critical care occurs when a physician or other qualified healthcare professional directly provides medical services for a critically ill or critically injured patient.

Document These Requirements For Critical Care

FAQ 2: What requirements must a provider meet to justify using the critical care E/M codes?

Answer: To qualify for critical care, a service must meet all of the following requirements:

• The patient must be critically ill/injured — have vital organ failure or a life-threatening health condition.
• The physician must perform the critical care services, including using high-complexity decision making to assess, manipulate, and support vital system functions to treat vital organ system failure or to prevent further life-threatening conditions.
• All critical care services must last at least 30 minutes on a given date of service. The time can be continuous or intermittent.

Don’t miss: If the physician provides services for a patient who is not critically ill but is in the critical care unit, you should report another appropriate E/M code, not a critical care code, according to the CPT® guidelines.

Coders must remember that physicians can perform critical care anywhere, not just in the intensive care unit (ICU) or emergency room (ER), reiterates Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey. Critical care is not based on the location of service, but instead, this term describes a type of care.

Beware Services Bundled Into Critical Care

FAQ 3: My provider performed gastric intubation, code 43752 (Naso- or oro-gastric tube placement, requiring physician’s skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report)), along with 99291 for a critically ill patient. Can we report the intubation separately?

Answer: No. The CPT^® critical care guidelines includes a specific list of services that are bundled into the professional components of critical care that you should not report separately when performed by the physician providing the critical care during the critical care period. Gastric intubation is one of these services.

The entire list is as follows:

• The interpretation of cardiac output measurements (93561, 93562)
• Pulse oximetry (94760-94761, 94762)
• Blood gases, and collection and interpretation of physiologic data (eg, ECGs, blood pressures, hematologic data)
• Chest x-rays, professional component (71045, 71046)
• Gastric intubation (43752-43753)
• Temporary transcutaneous pacing (92953)
• Ventilator management (94002-94004, 94660, 94662)
• Vascular access procedures (36000, 36410, 36415, 36591, 36600).

Mind Time for Critical Care

FAQ 4: How important is it for providers to document how much time they spend with patients during critical care services?

Answer: Time is a vital component of the critical care codes, and the surgeon must note time in the medical record.

“The documentation must include the total time the physician spent in critical care for/with the patient,” emphasizes Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America. “It does not have to be continuous, but it does have to be the total time on one full calendar day. Without this, the coding team would never know how long Dr. X spent with the patient.”

Key: You should report 99291 for the first 30-74 minutes of critical care on a given date. You should report 99291 only once per date even if the time the physician spends is not continuous on that date. Then, you should report +99292 for additional block(s) of time of up to 30 minutes each beyond the first 74 minutes.

Exception: You should report critical care of less than 30 minutes total duration on a given date with the appropriate E/M code, not a critical care code.

What counts: According to CPT^® guidelines, “the time that can be reported as critical care is the time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit.”

That includes time on the floor reviewing test results, discussing the patient’s care with other medical staff, or even with “family members or surrogate decision makers,” when the patient lacks capacity to participate, according to the guidelines. Don’t count time the physician spends outside the unit when not immediately available to the patient.