General Surgery Coding Alert

Not all ICU patients are critical, and not all critical patients are in the ICU

If reporting adult critical care services (99291-99292) leaves you with more questions than answers, here's the help you-ve been searching for.

The five question-and-answer scenarios below should solve all of your most common critical care dilemmas.

1. What Qualifies a Patient for Critical Care?

A critical care patient must be -critically ill- or -critically injured,- according to CPT guidelines. A critical illness or injury -acutely impair[s] one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition.-
 
-In other words, the patient is in immediate, mortal danger without continued, high-level physician involvement,- says Caral Edelberg, CPC, CCS-P, president, chief executive officer and founder of Medical Management Resources of TEAMHealth in Jacksonville, Fla.

Conditions that could call for critical care include (but are not limited to) central nervous system failure, circulatory failure, shock, and renal hepatic, metabolic and/or respiratory failure, according to CPT instructions.

Important: You may use critical care codes for a -stable- patient, but only if the physician's continued focused attention is preventing the patient's condition from deteriorating further.

-If the condition doesn't have the possibility of becoming a truly life-threatening situation, it's probably not critical care,- Edelberg says.

Critical Care Bonus Tip 1: -Critical- Isn't a Place

You cannot use critical care codes simply because the patient resides in an -intensive- or -critical- care unit, including coronary care units, respiratory care units or an emergency care facility. By the same token, a patient needn't be housed in such a unit to qualify for critical care.

The bottom line: Although physicians usually end up treating critical care patients in the designated critical care unit (CCU) or intensive care unit (ICU), critical care can take place anywhere in the hospital, says Valrie Hall, CCS, with Peak Health Solutions.

 
Example: The surgeon attends to a patient with a large penetrating wound who has gone into shock and respiratory failure. The surgeon is able to stabilize the patient after 30 minutes, but his condition remains such that he could -go either way.- After another three hours, the patient stabilizes to the point that he is no longer in immediate danger of death.

In this case, you can report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 74 minutes and +99292 (- each additional 30 minutes [list separately in addition to code for primary service]) x 5 for the remaining two hours and 15 minutes. 

2. Is There a Minimum Time for Critical Care?

The physician must spend a minimum of 30 minutes administering critical care services before a visit qualifies as critical care as described by 99291, according to CPT. For critical care services lasting fewer than 30 minutes, you will choose an appropriate E/M service code, says Susan Allen, CPC, compliance coder with JSA Healthcare in St. Petersburg, Fla.

Example: In the emergency department (ED), the surgeon again tends to a patient experiencing shock. In this case the surgeon is able to stabilize the patient after 25 minutes, after which the patient is no longer in immediate, life-threatening danger.

Because the critical care did not extend to 30 minutes or beyond, you should choose a standard ED visit (such as 99285, Emergency department visit for the evaluation and management of a patient ...) rather than 99291.

3. What Activities Count Toward Critical Care Time?

You may count toward critical care time spent -engaged in work directly related to the individual patient's care whether that time was spent at the immediate bedside or elsewhere on the floor or unit,- according to CPT [emphasis added].

For instance: Time the surgeon spends reviewing tests or discussing the patient's condition with other staff, documenting critical care services, or gathering information from family or surrogate decision-makers when the patient is unable to participate in discussions may count toward critical care, even though these activities may not occur at the patient's bedside.

Critical Care Bonus Tip 2: Multiple-Day Care Is OK

CPT does not limit the units of critical care you may report, and even goes so far as to state, -Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided the patient's condition -- continues to meet the definition of -critical- required to report critical care services.
 Note, however, that because critical care services are expensive, payers will likely demand a high level of documentation before paying out.

Care must be exclusive: The physician must attend exclusively to that patient during documented time for a service to qualify as critical care, Allen says. Therefore, if the surgeon attends to more than one patient in a given time period, he could not have administered critical care.

In addition, you may not count separately billable procedures in the time calculation (see below). -You should make a note in the record that indicates that the (critical care) time is exclusive of otherwise billable procedures,- Edelberg says. -Auditors look for that.-

4. Must Critical Care Time Be Contiguous?

The time the physician may count toward critical care need not be contiguous. -The time requirement is cumulative for a single date of service,- Allen says. -But you should document well any time the physician spends directly relating to the patient's care.-

In other words: If the physician provides one hour of critical care to stabilize the patient, but the patient's condition deteriorates later that same day and the physician must provide another hour of service, you may report 99291 (for the first hour) and 99292 x 2 (for the remaining hour), even though the services were not continuous.

5. Can You Report Other Same-Day Services?

Critical care is not an all-inclusive service. The only services specifically included in critical care consist of cardiac output measurements, chest x-rays, pulse oximetry, information data stored in computers, blood gasses, gastric intubation, temporary transcutaneous pacing, ventilatory management, and certain vascular access procedures. If the physician performs any of these services, you should not report them separately from the critical care.

Important: To get paid for critical care that occurs on the same day as a separate procedure, 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, says Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI, an ED billing company in Stoneham, Mass.

Example: The surgeon attending to the shock patient with the penetrating wound in the first example above must perform endotracheal intubation to support the patient's breathing. You should report this procedure separately using 31500 (Intubation, endotracheal, emergency procedure), then report the appropriate critical care code(s) with modifier 25 appended (in other words, 99291-25, 99292 x 5).