EM Coding Alert

Beware of guidelines, bundling, and time reporting.

In E/M Coding Alert Volume 7 Number 7, we answered some frequently asked questions regarding the critical care E/M codes — 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (… each additional 30 minutes (List separately in addition to code for primary service)).

Our answers prompted a number of subsequent questions that we answer here to help you further hone your critical care coding skills.

Always Meet These Requirements for Critical Care

Question 1:  To qualify for critical care, which specific requirements must a service meet?

Answer: Critical care occurs when a physician or other qualified healthcare professional directly provides medical services for a critically ill or critically injured patient. As always, the documentation must support the necessity of the critical care service.

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 CPT^® guidelines.

Coders must remember that physicians can perform critical care anywhere, not just in the ICU or 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

Question 2: My provider performed pulse oximetry, code 94760, along with 99291 for a critically ill patient. Can we report the pulse oximetry 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. Pulse oximetry is one of these services.

The entire list is as follows:

• Interpretation of cardiac output measurements (93561, 93562)
• Pulse oximetry (94760-94761, 94762)
• Blood gases, and collection and interpretation of physiologic data (e.g. 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).

Don’t miss: When your physician provides any of the above services during a critical care session, you should not report them separately. However, facilities can report these services separately.

Mind Time for Critical Care

Question 3: How important is it for the provider to document how much time he spends with the patient during critical care services?

Answer: Time is a vital component of the critical care codes. The physician should always record the time he spent with the patient in the medical documentation.

“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.”

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. 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.

Then, you should report +99292 for additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes.

“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,” according to the CPT^® guidelines.

You can report critical care: The physician can report the time he spends on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff, or documenting critical care services in the medical record as critical care, even though these services did not occur at the patient’s bedside.

Also, “when the patient is unable or lacks capacity to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient,” per the guidelines.

Don’t report critical care: However, any time the physician spends in activities outside of the unit or floor, such as telephone calls he takes at home, in his office, or somewhere else in the hospital, would not count as critical care because the physician is not immediately available to the patient in these circumstances.

Additionally, if the physician spends time in activities that do not directly contribute to the patient’s treatment, such as administrative meetings, he cannot report these services as critical care, even if he performs these activities in the critical care unit, according to the guidelines.

Putting It All Together

Question 4: I’m still not certain about when I could report the critical care codes. Can you give me an example?

Answer: A cardiologist performs critical care services where he uses high-complexity decision making to assess, manipulate, and support vital system functions to treat a patient who suffers from circulatory failure. The cardiologist documents that he spent 1 hour and 15 minutes with the patient. You should report 99291, +99292 on your claim.