General Surgery Coding Alert

Don’t unbundle 99291 services.

Just because CPT^® 2023 didn’t revise critical care codes doesn’t mean you’re off the hook for updating how you report these services.

Backstory: CPT^® 2023 revised most hospital/inpatient evaluation and management (E/M) codes (See General Surgery Coding Alert Vol. 24 No. 12, “Embrace E/M Shift to Time or MDM”), but critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (… each additional 30 minutes (List separately in addition to code for primary service)) stood fast. At the same time, the CY 2023 Medicare Physician Fee Schedule (MPFS) Final Rule had some guidance of its own to impose on using those codes.

Key: Read on to learn what has and hasn’t changed for billing critical care codes, and other crucial basics of reporting 99291/+99292 this year.

Define Critical Illness, Injury

The first thing to know about critical care coding: The patient must be critically ill or injured to report 99291/+99292.

“CPT^® states that a critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition,” explains Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Michigan.

The physician will be the one deciding whether the patient is critically ill or injured; coders, however, can be on the lookout for potential critical care in certain situations. For instance, according to Young, examples of potential critical care scenarios include:

• Patient with atrial fibrillation (heart in irregular rhythm posing threat to life)
• Patient involved in motorcycle accident who comes into ED with multiple injuries (fractures, injured organs, etc.)
• Physician stays with patient to stabilize function while specialists address fractures, contusions, abrasions, etc.

Remember: Critical care services aren’t conveniently provided on daily rounds. “They are provided when an acute change in patient status requires care to save or stabilize the patient,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia.

Guidance: The CPT^® guidelines indicate that the medical record must demonstrate the patient has an acute impairment of one or more vital organ systems and has a high probability of imminent or life-threatening deterioration. Also, providers must demonstrate “high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition,” the guidelines say.

Location: While you may think of critical care as being typically performed in the hospital setting, the reality is that “critical care is not determined by the location in which the care is being delivered,” according to Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia. As CPT^® puts it: “Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility.”

This means “the key to applying a critical care code is understanding that the service must be medically necessary and meet the criteria of critical care,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “And providers may report critical care even in a hospital setting if they are specifically the one managing the problem that is critical in nature.”

Include These Services When Reporting Critical Care

There are a lot of services that could occur while your physician provides critical care. Many of these services are bundled into the critical care codes, and you should never code for them and 99291/+99292 for the same patient encounter.

CPT^® lists the following services as bundled into 99291/+99292:

• Interpretation of cardiac output measurements (+93598)
• Chest X-rays (71045, 71046)
• Pulse oximetry (94760, 94761, 94762)
• Blood gases, and collection and interpretation of physiologic data (eg, ECGs, blood pressures, hematologic data)
• Gastric intubation (43752, 43753)
• Temporary transcutaneous pacing (92953)
• Ventilatory management (94002-94004, 94660, 94662
• Vascular access procedures (36000, 36410, 36415, 36591, 36600)

“Any services performed that are not included in this listing should be reported separately,” according to CPT^®.

Don’t Forget Non-Continuous Critical Care Minutes

Coders need to remember that critical care time does not need to be continuous. For example, the physician could provide 55 minutes of critical care for a patient in the morning, then 23 more in the afternoon. If coders miss the afternoon minutes, they’ll only be able to report 99291. If, however, the coder captures both instances of critical care and adds them up, they might be able to report 99291 and +99292 (for payers that follow CPT^® rules).

MPFS rule: The Centers for Medicare & Medicaid Services (CMS) is not in alignment with CPT^® on the time thresholds required for reporting the add-on code +99292 to the first 74 minutes of critical care represented by 99291. CMS insists on a 30-minute buffer before applying +99292, publishing the following guidance in the CY 2023 MPFS final rule to broaden the time ruling to include care by a single or multiple practitioners:

“As correctly stated elsewhere in the CY 2022 [M]PFS final rule (regarding critical care furnished by single physicians at 86 FR 65160, and regarding concurrent care furnished by multiple practitioners in the same group and the same specialty to the same patient at 86 FR 65162), our policy is that CPT^® code 99291 is reportable for the first 30-74 minutes of critical care services furnished to a patient on a given date. CPT^® code +99292 is reportable for additional, complete 30-minute time increments furnished to the same patient (74 + 30 = 104 minutes). We clarify that our policy is the same for critical care whether the patient is receiving care from one physician, multiple practitioners in the same group and specialty who are providing concurrent care, or physicians and NPPs [non-physician practitioners] who are billing critical care as a split (or shared) visit.”