General Surgery Coding Alert

To determine if your surgeon actually provided critical care services, you-ll need to ask important questions about the patient's status. And after you have identified an encounter as critical care, you-ll need to be sure that the surgeon has documented the critical care time meticulously to file a proper claim.

You-ll also need to decide which services are part of the critical care package and which services you may report separately.

With so much to consider, ease your burden with this step-by-step approach.

You-ll first want to find out if the patient has a critical illness or injury.-If the patient is not critically ill or injured, you cannot report critical care services and should instead rely on an appropriate standard E/M service code, says Shelley Bellm, CPC, physician relations and coding manager at Colorado Mountain Medical in Edwards.

Patients requiring critical care have acute "impairment of one or more vital organ systems, such that there is risk (i.e., high probability) of imminent or life-threatening deterioration in the patient's condition," Bellm says. "Critical care requires high-complexity decision-making to assess and support the vital organ systems- functionality to prevent deterioration in the patient's condition."

If the physician provides services such as these for at least 30 minutes, it could be a critical care encounter, according to CPT guidelines.

For instance, conditions that might require critical care can include acute myocardial infarction, respiratory arrest and severe blood loss, Bellm says.

Example: The surgeon treats a trauma patient experiencing respiratory arrest in a hospital emergency department. The physician performs cardiopulmonary resuscitation (CPR) for 15 minutes and then monitors the patient's breathing patterns for 45 minutes.

On this claim, you should report the critical care service and the CPR, Bellm says, as follows:

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

- 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest]) for the CPR

- 799.1 (Respiratory arrest) linked to 99291 and 92950 to prove medical necessity for both services.

Advise your physicians that when documenting this claim, they should be sure to note the start and stop times for the CPR and the critical care so the insurer knows how much critical care time you are coding for on the claim.

Important: To get paid for critical care that occurs on the same day as a separate procedure (as in this case), you need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the critical care code(s).

Timing Matters for Critical Care

Remember that for Medicare payers, and others who follow Medicare rules, you can report critical care in the postoperative period only if the surgeon treats the patient for a problem unrelated to the surgery.

For example, if the surgeon repairs a ruptured aortic aneurysm (34800, Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis) and, during the service's global period, provides critical care for complications arising from the procedure or the aneurysm, you cannot report the critical care separately. Medicare bundles all "complications" unless they require a return trip to the operating room.

Although you may report CPR separately with critical care, CPT bundles many common "emergency" procedures into 99291-99292, including:

--Interpretation of cardiac output measurements (93561, 93562)

--Chest x-rays (71010, 71015, 71020)

--Blood gases (82800, 82803, 82805, 82810)

--Vascular access procedures (36000, 36410, 36415, 36540, 36600)

--Computer-stored patient data, such as electrocardiograms (ECGs), blood pressure readings, hematologic data (99090)

--Gastric intubation (43752, 91105)

--Ventilator management (94002-94004, 94660, 94662)

--Pulse oximetry (94760, 94761, 94762)

--Temporary transcutaneous pacing (92953).

Although physicians typically provide critical care in certain settings (such as an emergency department or intensive care unit [ICU]), location will not drive your critical care coding, says Denae M. Merrill, CPC, coder for Covenant MSO in Saginaw, Mich. "Critical care can occur in an inpatient or outpatient setting, as well as any location within the inpatient status," she says.

What matters is the patient's status--- if the patient is critically ill or injured and the physician spends at least 30 minutes on care services for the patient, critical care codes may be appropriate.

One mistake some coders often make is thinking that the physician must be face-to-face with the patient to provide critical care. In fact, the physician can still give a patient critical care while not at the patient's bedside, Bellm says.

Time spent with the individual patient is part of critical care, but so is "time spent engaged in work directly related to the individual patient's care, whether at the immediate bedside or elsewhere on the floor or unit," Bellm says.

Best bet: When adding up critical care minutes, count any time "that the physician is engaged in work directly related to the patient's care--- reviewing the patient's chart, ordering tests, discussion with medical staff, etc.," Bellm says. If the patient is unable to participate in discussions, you may report time spent with family members or other decision-makers obtaining a medical history, reviewing the patient's condition or prognosis, or discussing treatment or limitation(s) of treatment in critical care time as well, she says--- as long as the conversation bears directly on the patient's management. But you cannot include updates on the patient's status in critical care time.

Remember: The physician's critical care service does not need to be continuous. "Critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous," CPT says. The key is documenting the time the physician spends with the critical care patient.

Suppose the physician provides 20 minutes of critical care to patient A. He goes to another floor to check on patient B for 15 minutes, then returns to patient A to provide 30 more minutes of critical care. In this scenario, you can report 50 minutes of critical care time for patient A as long as the documentation accurately reflects the encounter.