Revised Critical Care Codes Accepted by Medicare
Published on Tue Feb 01, 2000
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 [...]
