Gastroenterology Coding Alert

Get More out of 99291 and 99292

Insufficient physician documentation - not your coding skills - could be jeopardizing reimbursement for your critical care claims when dealing with acute patient conditions such as severe gastrointestinal bleeding (578.9 Hemorrhage of gastrointestinal tract, unspecified).
 
Tell your doctors about the payment they sacrifice if they don't understand when and how to document critical care, says James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa. - and then help them out with the information below. 'High Probability' Opens Reimbursement Doors Critical care codes 99291 and 99292 may cover more services than you or your gastroenterologist thinks it does.
 
Critical care services include the direct delivery of medical care to a critically ill or injured patient, says Deborah Grider, CPC, CPC-H, CCS-P, CCP, president of Medical Professionals Inc. in Indianapolis. A critical care patient must have the "high probability of imminent or life-threatening deterioration," according to CPT.
 
But don't overlook the phrase "high probability" - that's what could increase your revenue. A patient doesn't have to be on her deathbed to require these services. The necessary condition is the risk for, not the presence of, instability. "Physicians so often fail to document critical care time on patients whose condition could deteriorate rapidly into a life-threatening situation," says Nettie McFarland, RHIT, CCS-P, at Healthcare Billing Systems Inc. in South Daytona, Fla.
 
Consider the following example of a gastroenterologist providing critical care services for a patient with chronic liver disease (571.9): Your physician directs one of her patients who has been having severe gastrointestinal bleeding to meet her in the emergency department (ED) of your local hospital. The bleeding is heavy, and the physician cannot immediately identify its origin. Although the patient is technically not unstable, there is an imminent risk, a high probability, of him bleeding out. The gastroenterologist sees the patient, conducts tests and analyzes results, and consults with other physicians for more than 30 minutes. You should code 99291 (... first 30-74 minutes) and +99292 (... each additional 30 minutes), while critical care is being administered.
 
In this case, the presenting problem - not the final diagnosis or condition - determines the risk factor. The severe bleeding presents the potential for an unstable, high-risk condition, so diagnosing and treating the crisis warrants critical care codes.
 
Here's a useful rule of thumb for determining critical care status: For you to report critical care, the patient must be on a medication or a treatment regimen that is supporting an organ system, and without that treatment the patient would be unstable, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. This approach will keep you from over-reporting critical [...]