Gastroenterology Coding Alert

Here's what you need to have -- and don't -- when reporting critical care

If you meet two important critical care requirements in the time and documentation departments, your claim will succeed even if the physician is not in the emergency department or other -critical care area.-

Important: A gastroenterologist can provide critical care just about anywhere he meets the patient and provides the service. A patient who receives critical care -does not actually have to be in a critical care setting,- says Jacquelyn Dodge, receptionist/coder at Eric A. Wingerson, DO, in Idaho Falls, Idaho.

Myth 1: You Can Only Provide Critical Care in ED

If you think that your gastroenterologist has to be in an emergency department (ED) or other -critical care area,- you may be missing out on well-deserved reimbursement. 

In other words, no matter the setting, you should base critical care on time only, for the critically ill or critically injured patient, meaning there is a high probability of imminent or life-threatening deterioration of the patient's condition, experts say.

Although most critical care occurs in an ED or other -critical care area,- Medicare pays for critical care provided in any location if you meet the guidelines. Conversely, a patient's presence in an intensive or critical care unit doesn't necessarily qualify as a critical care situation.

Myth 2: Documentation Is Secondary to Setting

Even though the critical care may have occurred in a nontraditional setting, the service is still a viable critical care claim--as long as you meet documentation requirements, experts say.

-Whether a service meets critical care requirements depends on treatment, level of care performed, gravity of the patient's condition, and the physician's documentation and notes,- says Todd Thomas, CPC, CCS-P, president of Thomas and Associates in Oklahoma City. In critical care, setting is secondary to documentation.

Heed this advice: To lock up reimbursement for your critical care claims, check out this short list of tips on documentation:

Note a start and stop time for the critical care services. Also document time spent on all care management services provided in that time. If the gastroenterologist provided critical care and another service in the same session, be sure to explain how much time the physician spent providing each service.

Give details about all the services the physician provides. These services would include the usual E/M components. Other services that may (or may not) be part of a carrier's critical care package include:

- interpretation of cardiac output studies
- chest x-rays
- blood gases
- electrocardiogram
- blood pressures
- hematological testing
- gastric intubations.

Try This Critical Care Scenario

Now that you-ve busted the above two myths, try your hand at the following critical care scenario.

Scenario: A patient with macronodular cirrhosis of the liver presents to the hospital where the gastroenterologist treats him for severe gastrointestinal bleeding. The patient is hemorrhaging heavily, and the physician needs to perform bedside care and management before deciding whether he will conduct an endoscopy to find the bleeding's origin and stop it.

Solution: The gastroenterologist documents 47 minutes of critical care, during which time he:

- lavages blood from the patient
- conducts tests and analyzes results
- consults with other physicians.

On your claim, you should:

- report 99291 for the critical care services

- attach 578.9 (Hemorrhage of gastrointestinal tract, unspecified) and 571.5 (Cirrhosis of liver without mention of alcohol) to 99291 to show the payer why critical care was medically necessary.

What you need: The gastroenterologist documented the 47 minutes of critical care services, so you need to include this with your claim. Also, make certain that the physician gives the details about what he performed.

What you don't need: The gastroenterologist performed this service in a hospital setting, but you do not need this location to successfully report critical care services.