EM Coding Alert

Experts: You’ll often see these separately reportable services on 99291 claims.

Determining if your physician provided service that qualifies for critical care coding is your first step in deciding whether or not to report 99291.

Not so fast: There’s more to consider, however, if you want to optimize your legit reimbursement possibilities. Some services your provider might perform during critical care are separately reportable from 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]).

“Unless billing for the service [separately] is prohibited for the site of service or by specific payer rules,” you can report some services in addition to critical care, reports Caral Edelberg, CPC, CPMA, CCS-P, CAC, CHC, Chief Executive Officer of Edelberg and Associates in Atlanta.

Read on for some advice on spotting the separate services and coding them correctly, so you’ll be ready the next time your provider treats a patient who exhibits a critical illness or injury such that possible death or loss of function could occur without the intensive care.

Know CC Bundles to Aid Your Coding

First, coders need to get a grip on the services that CPT^® bundles into 99291 and 99292. According to CPT^® 2016, you cannot report the following services in conjunction with critical care:

• cardiac output measurements (93561, 93562)
• pulse oximetry (94760, 94761, 94762)
• chest x–rays (71010, 71015, 71020)
• blood gases and information data stored in computers (99090)
• gastric intubation (43752, 91105)
• transcutaneous pacing (92953)
• ventilator management (94002–94004, 94660, 94662) and
• vascular access procedures (36000, 36410, 36415, 36591, 36600).

Caveat: CMS includes only the above services in critical care, though some other payers include or exclude different services. You’ll want to check with your top payers to for a definitive list of their individual critical care bundles.

Do this: When your provider performs one of the procedures listed above during the course of a critical care encounter, count the time spent toward the total critical care minutes. So if the physician performs ventilator management during a critical care encounter, the service is part of the work units for 99291 and 99292.

Check for CPR, Intubation on CC Claims

While there is no definitive list of separately reportable services, there are some procedures that physicians perform more often than others during critical care, experts say.

“CPR [cardiopulmonary resuscitation] and endotracheal intubation are probably the most well-known services that you can report separately from 99291,” Edelberg says.

Jim Strafford, CEDC, MCS-P, principal of Strafford Consulting in Bryn Mawr, Pa., agrees that CPR and intubation are the most common services you’ll see with 99291 and 99292. Consider this example from Strafford:

An 84-year-old patient who has a history of unilateral pulmonary emphysema reports to the emergency department (ED) in severe respiratory arrest. The physician performs 11 minutes of CPR, takes 22 minutes to intubate the patient and then performs 72 minutes of critical care.

On the claim, you would report:

• 99291 for the first 72 minutes of critical care
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service)  appended to 99291 to show that the critical care was a separate service from the CPR and intubation
• 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest]) for the CPR
• 31500 (Intubation, endotracheal, emergency procedure) for the intubation
• J96.00 (Acute respiratory failure, unspecified whether with hypoxia or hypercapnia) appended to 99291, 99292, 92950, and 31500 to represent the patient’s respiratory failure
• J43.0 (Unilateral pulmonary emphysema [MacLeod’s syndrome]) appended to 99291, 99292, 92950, and 31500 to represent the patient’s emphysema.

Remember Documentation on CC/Separate Service Claims

You should note the amount of critical care time on the encounter form, but it’s not absolutely necessary to record start and stop times, Strafford says. “It’s rare to see start/stop times on critical care claims,” he says. “It’s not [in most] physicians’ psyches to record a start and stop times.”

If the physician does indicate the start and stop time for critical care, be sure to include in on the claim. This documentation is not, however, 100 percent necessary for a successful critical care claim.

What you might see in the notes is a breakdown of the total session, such as: “Provided 72 minutes of critical care. Also CPR and endo intubation.” When you see this type of documentation, be sure to include it on your critical care claims. You also may need to ask the physician to addend the note to include the minutes spent doing CPR and the intubation, if it is not already included within the medical record.