Gastroenterology Coding Alert

The Health Care Financing Administration (HCFA) and CPT often have different definitions that cause significant confusion for gastroenterologists. But HCFA recently accepted the CPTs rules for reporting critical care, which should make using these codes easier to understand.

In December 1999, HCFA released a program memorandum (transmittal no. B-99-43) that clarifies several issues related to the interpretation, reporting and payment of critical care codes 99291 and 99292, which were revised this year. Most significantly, the CPT 2000 definition no longer uses the term unstable to describe critically ill or injured patients.

A gastroenterologist might deliver critical care services, for example, when a patient is having massive gastrointestinal bleeding caused by an ulcer or cirrhosis. In that situation, the gastroenterologist may be at the patients hospital bedside, determining the source of the bleeding, suctioning blood and monitoring the patients vital signs. Other circumstances that might require a gastroenterologist to provide critical care include post-operative complications, treatment for shock or the insertion of a tube.

The HCFA memo states that Medicare generally will accept the revised CPT definition, which the agency does not always do. CPT and Medicare are often looked at as being two different standards, says Jan Loomis, director of coding and documentation for TeamHealth West, a Pleasanton, Calif., affiliate of TeamHealth that provides emergency physician staffing and critical care specialists to hospitals. On this issue, Medicare is pretty much in conjunction with the CPT, and this memo provides a good basis for what constitutes critical careregardless of the payer.

Editors note: For a more extensive analysis of the CPT 2000s section on critical care, please see CPT 2000 Changes for Critical Care Mean Billing for Time on page 26 of the December 1999 Gastroenterology Coding Alert.

Additional Medicare Criteria for Critical Care

According to the memo, Medicare also will add two medical review criteria that must be met for an evaluation and management (E/M) service to qualify as critical care. These should be looked at as additional screens to add further clarification and focus as to what is a critical care service, explains Loomis.

First, there is the clinical condition criterion, which HCFA defines as a high probability of sudden, clinically significant, or life threatening deterioration in the patients condition, which requires the highest level of physician preparedness to intervene urgently.

The phrase clinically significant is what Loomis considers most important here. This does not mean just life threatening, she explains. A patients vital signs could be normal, but unless the gastroenterologist does something, the patients condition could deteriorate.

Second, there is a treatment criterion, which HCFA defines as [c]ritical care services [that] require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patients condition.

The treatment criterion reinforces the clinical condition criterion, according to Loomis. The gastroenterologist needs to do something to keep the patients condition from worsening.

Full Attention of Gastroenterologist Required

CPT 2000 also eliminated the requirement for constant attention from the critical care codes and replaced it with the phrase full attention. Although HCFA accepts this revision, there are several medical review guidelines regarding full attention and the use of physician time that must be met to be eligible for Medicare reimbursement:

1. The gastroenterologists progress note must contain documentation of the total time involved providing critical care services. If the time is not legibly and unequivocally documented, the memo stresses, the claim will be subject to recoding or denial.

2. Time spent performing procedures that are not bundled into the critical care codes may not be included and counted toward critical care time.The physicians progress note must document that time involved in the performance of separately billable procedures was not counted toward critical care time, states the memo.

3. When the patient is unable to participate in giving a history and/or making treatment decisions, the gastroenterologist may count the time spent with family or a surrogate decision maker in obtaining patient background information or discussing treatment decisions as critical care. Informing the patients family of his or her prognosis, however, is not included as a critical care service, explains Loomis.

Use Modifier -25 to Increase Reimbursement

HCFAs memo also provides some support for gastroenterologists who are struggling to get paid for critical care services billed on the same day as a procedure. It states that Medicare should reimburse for critical care services performed on the same day as a procedure with a global fee period as long as it is a significant, separately identifiable evaluation and management service that is above and beyond the usual pre- and post-operative care associated with the procedure that is performed.

When the -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is attached to the CPT code, the memo encourages carriers to honor the claim. Carriers are reminded that critical care codes are evaluation and management services and that the discussion of payment for services billed with CPT modifier -25 also applies to critical care codes, it states.

Note: Relative value units for this years critical care codes were reduced from 5.61 to 5.21 for code 99291 and from 2.73 to 2.60 for code 99292. Loomis believes this change was made by HCFA in anticipation of an increased number of critical care claims because the unstable and constant attention requirements were removed with the CPT 2000 definition.

For a copy of the HCFA memo on critical care, go to http://www.hcfa.gov/pubforms/transmit/b994360.htm.