Gastroenterology Coding Alert

Question: Our gastroenterologist recently had to spend a lot of time and effort to control bleeding on a critically ill patient. Should I report the extra time and effort spent on the patient with a critical care code or with a modifier 22?

Vermont Subscriber

Answer: To report the control of bleeding under the critical care services code, the condition of the patient must be critical as described in the guidelines laid down by CPT®. As per the CPT® guidelines, "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 also states that "Critical care services must be medically necessary and reasonable". For more details, check http://www.cms.gov/manuals/downloads/clm104c12.pdf.

If the condition of the patient satisfies the guidelines laid down by CPT® for a critically ill patient, then you can report the control of bleeding performed by your gastroenterologist using the CPT® codes 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 and +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 of services provided.

When the patient's condition does not satisfy the CPT® guidelines for a critically ill patient, you cannot claim the control of bleeding using the critical care codes mentioned above. In such a scenario, you can use the appropriate E/M code for the services provided (e.g., CPT® codes 99231-99233, Subsequent hospital care, per day...).

In the scenario of your gastroenterologist performing a procedure and additional time and effort was needed to control the bleeding, you can add the modifier 22 (Increased procedural service) to the code that you are reporting for the procedure. The modifier will help the payer know that your gastroenterologist had to spend extra time on the patient than was necessary for the procedure done. Note that you cannot append the modifier 22 to an E/M code. Also, you cannot use the modifier 22 if your gastroenterologist controlled any bleeding induced during the procedure.