Gastroenterology Coding Alert

Your gastroenterologist reports to a local emergency department (ED) and provides a patient with 42 minutes of critical care; you don't recognize the patient as critically injured, so you report a level-five ED E/M instead. No big deal ... right?

Wrong: The critical care code pays around $45 more per claim. This FAQ will help you snare all the cash you can on each potential critical care claim.

"When the nurse turns to you and says, 'We need you in room 4 NOW,' there's a pretty good chance you are about to see a critically ill patient who needs some type of intervention to prevent further deterioration in their condition," explains Michael Lemanski, MD, billing director at Baystate Medical Center in Springfield, Mass. For coding purposes a patient must be critically ill or injured in order to receive critical care. "Critically ill or injured patients have one or more vital organ systems acutely impaired, and there is a high probability of imminent life-threatening deterioration in the patient's condition" if the physician does not intervene, explains Deb Williams, CPC, coding supervisor at Horizon Billing Specialists in Grand Rapids, Mich.

Without immediate physician intervention "the patient will only get worse very quickly -- and may die.

However, the physician must spend at least 30 minutes providing critical care before you can code for it,however," Lemanski continues. When coding critical care, you'll use 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 74 minutes, and +99292 (... each additional 30 minutes [List separately in addition to code for primary procedure]) for additional time beyond 74 minutes.

Best bet: Payers are going to take issue if you code +99292 for a minute or two of critical care. Only consider +99292 if the session goes at least 15 minutes beyond the initial 74 (89 total). So if the gastroenterologist provides 76 minutes of critical care, stick with 99291.

Some examples of patients that might receive critical care include:

• severe allergic reactions, as might happen with a Remicade infusion

• sepsis

• respiratory failure

• acute upper or lower gastrointestinal bleeding

• acute pancreatitis

• visceral perforation

• motor vehicle accident patients with multiple injuries

• myocardial infarction

• altered mental status.

However: A patient suffering from one of the listed conditions does not necessarily need critical care. The key to critical care patients is the potential for rapid deterioration without immediate physician intervention.

Just about any other service the physician provides to the critically ill or injured patient counts toward critical care time; these services include, but are not limited to:

• interpretation of cardiac output measurements

• x-rays

• pulse oximetry

• blood gasses

• tests that store information digitally (for instance, ECGs, blood pressures, hematologic data)

• gastric intubation

• temporary transcutaneous pacing

• ventilatory management

• vascular access procedures (excepting most of the central line codes).

Physician knowledge of this coding intricacy is not a given, explains Jim Strafford, CEDC, MCS-P, vice president of client services with Omega Healthcare. "A major issue with critical care is a lack of understanding on the part of docs as to what elements can get them to 30 minutes of critical care. I spoke with a physician yesterday who totally misunderstood time documentation requirements for critical care," he says.

Strafford's point hits home when you look at the numbers. If you report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), you'll rein in about $215 (5.99 transitioned facility relative value units [RVUs] multiplied by the temporary Medicare conversion rate of 36.0846).

Conversely, the highest-level ED E/M, 99285 (Emergency department visit for the evaluation and management of a patient ...), pays about $170 (4.74 RVUs multiplied by 36.0846). So be sure that you know which types of physician actions you can include in critical care time -- and which you cannot.

When totaling critical care minutes, you will need to deduct the time spent performing these activities from overall critical care time:

• CPR

• endotrachael intubation

• chest tube/central line insertion

• ultrasound interpretation

• laceration/orthopedic repairs

• endoscopy or colonoscopy.

You should also deduct teaching time aside from the critical care and time spent speaking with people other than the patient that does not directly bear on the patient's medical care.