Gastroenterology Coding Alert

Different specialties can claim critical care services when non-duplicative.

When your gastroenterologist provides critical care services as in the case of severe gastrointestinal bleeding due to cirrhosis or ulcers, you will need to concentrate on the patient's condition and time spent in attending to the patient. Read on to know more about when you can bill critical care services and other associated services provided to the same patient on the same day.

Assess Patient's Condition to Know if Critical Care can be Reported

Ensure that the patient's condition qualifies as critical. CPT® guidelines state that "critical care is the direct care provided by a physician to critically ill or injured patient" and "the critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition." CMS states that "Critical care services must be medically necessary and reasonable" and if services provided are not in accordance to the definitions of critical care services, then an appropriate E/M code should be used to report the services provided (e.g., CPT® codes 99231-99233, Subsequent hospital care, per day...). For more details, check http://www.cms.gov/manuals/downloads/clm104c12.pdf.

When your gastroenterologist provides critical care services, you report these services provided with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 30-74 minutes of services provided.

For any additional time that your gastroenterologist provides these services, you would use +99292 (Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes [List separately in addition to code for primary service]) for every additional 30 minutes.

Calculate Accurately Time Spent on Providing Critical Care

When your gastroenterologist provides critical care for a patient, the notes need to show more than support for the patient's critical status. "Critical care services is a time based service. The billing provider must document the total time spent evaluating and treating the critically ill patient," says Mary Mulholland, MHA, RN, CPC, with University of Pennsylvania Health System in Philadelphia. "Time counted towards critical care services may be continuous or intermittent. The provider must devote his full attention to the individual patient and cannot render care (an E/M or any other service) to any other patient during the reported time period."

"During this time the physician must devote full attention to the particular patient. This time may be spent at the patient's immediate bedside or elsewhere on the unit, so long as the physician is immediately available to the patient," says Mary I Falbo, MBA, CPC, President of Millennium Healthcare Consulting, Inc. in Lansdale, PA. So you need to document all the time spent that comes under the purview of critical care, for example, at bedside, discussion of the case with other staff, time spent with family recording history or making management decisions and reviewing results.

"Time spent performing allowed billable services should not be included (e.g., Insertion of an arterial line)," says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. "Time spent performing bundled services (reading an ECG, starting an IV or looking at x-rays or CT) should be included in the critical care time, if performed on the patient's floor/unit."

Observe Timing of Other E/M services Provided on Same Calendar Date

You will need to know when you can report E/M services and critical care services provided by your gastroenterologist to the same patient on the same day. "When the provider performs both an E/M service (outpatient or inpatient service) and critical care on the same calendar day, both services may be reported, as long as the E/M service preceded the critical care service," says Mulholland. "Providers are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims," says Falbo.

Example: A patient hospitalized with severe episodes of abdominal discomfort and diarrhea was seen in the morning for a level 2 subsequent hospital visit. The patient had earlier undergone paracentesis and was placed on diuretics for the management of ascites. The patient's condition deteriorated and our gastroenterologist suspected spontaneous bacterial peritonitis. The patient was moved to the MICU requiring 60 minutes of critical care time. You can code 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components...) with the modifier 59 along with 99291 for the day's efforts. A 59 (Distinct procedural service) modifier should be used to indicate that the critical care services were totally separate from the earlier E/M service.

Capture Critical Care Services Provided by Different Specialties

To support the necessity of critical care services provided by every specialty, the documentation should carry the date and time of services provided by the concerned specialties. However, you need to note that providers belonging to the same group can provide critical care services as long as they belong to different specialties and services provided are not duplicative.

Crucial: "Medically necessary critical care services provided on the same calendar date to the same patient by physicians representing different medical specialties that are not duplicative services are payable," states Falbo. "The concurrent care by each physician must be medically necessary, and not provided during the same time period, in order to ensure these services are eligible for separate reimbursement," Mulholland adds.