Gastroenterology Coding Alert

When a gastroenterologist leaves a critically ill patient's bedside to attend to another matter, that does not mean you have to permanently stop the critical care clock -- though you do have to quit counting minutes until the critical care resumes.

"Critical care time does not need to be continuous. For example, the physician could provide 35 minutes of CC in the morning, then 23 more in the afternoon," offers Michael Lemanski, MD, billing director at Baystate Medical Center in Springfield, Mass.

Consider this detailed GI example, courtesy of Lemanski: The gastroenterologist meets a 68-year-old woman with cirrhosis at the local ED. She appears very pale, hypotensive, and tachycardic. The gastroenterologist orders two large bore IVs so she can administer fluid boluses and get the patient cross-matched for blood. The gastroenterologist documents that he spent 67 minutes providing critical care for the patient, from 9:23 a.m. until 10:30 a.m.

The patient stabilizes and is admitted to the hospital. About 90 minutes later, a nurse approaches the gastroenterologist and says the patient is diaphoretic and complaining of chest pain. Her blood pressure is again low and an EKG shows new changes consistent with ischemia.

"Several highly complex and difficult decisions lie ahead, such as whether to administer aspirin to a patient with a GI bleed, or nitroglycerin to a patient who presented hypotensive," explains Lemanski.

The gastroenterologist discusses the situation with the patient and her family, and then treats her hypotension and active chest pain, consults with cardiology, and takes the patient to the cath lab. The gastroenterologist notes another 25 minutes of critical care for this encounter.

In this instance, the gastroenterologist provided 92 minutes of non-consecutive critical care. On the claim, report the following:

• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 74 minutes of critical care

• +99292 (... each additional 30 minutes [List separately in addition to code for primary procedure]) for the next 18 minutes of critical care.

Append the following diagnosis codes to both critical care codes:

• 578.9 (Hemorrhage of gastrointestinal tract, unspecified) for the GI bleed

• 458.9 (Hypotension, unspecified) for the hypotension

• 785.0 (Tachycardia, unspecified) for the tachycardia

• 413.9 (Angina pectoris; other and unspecified angina pectoris) for the angina

• 571.2 (Alcoholic cirrhosis of liver) to represent the cirrhosis.