General Surgery Coding Alert

CPT and Medicare have clarified and somewhat eased the stringent guidelines for critical care (99291-99292), but billing for these relatively well-reimbursed evaluation and management (E/M) services is still difficult for surgeons.

Many of the procedures surgeons perform have a global package, which bundles most E/M services into the reimbursement for the procedure. In addition, when general surgeons see trauma patients and provide critical care services, other specialists often are involved as well. Consequently, the surgeon frequently cannot bill because only one involved physician can code for critical care, says Terry Fletcher, BS, CPC, an independent coding and reimbursement specialist in Laguna Beach, Calif.

If a team of physicians is working on the patient, the doctor involved in the direct stabilization work on the patient should be the one billing for the critical care, Fletcher says.

General surgeons, however, can bill for critical care in addition to the surgical procedure if four criteria are met:

1. The patients problems are unrelated to the surgery performed;
2. The services meet critical care guidelines;
3. They dont see other patients while the services are performed; and
4. All of the above are well documented.

For example, a general surgeon performs a colectomy on an elderly female trauma patient, and later the patient has a myocardial infarction in the middle of the night. The first responding physician starts CPR, intubates and shocks the patient, getting her back in sinus rhythm. Meanwhile, the general surgeon has been called in and assumes care. Once the patients heart rhythm returns, she has low blood pressure, so the surgeon moves her to the intensive care unit (ICU) and places her on a ventilator. Labs then are ordered as the general surgeon manages the care of the patient until a cardiologist or internal medical consultant arrives.

In this situation, the general surgeon could bill critical care for the time spent with the patient until the consultant arrives.

CPT and Medicare Changes

The words unstable and constant may have been removed from CPT guidelines on critical care codes, but general surgeons still need to use these relatively well-reimbursed E/M codes carefully and shouldnt use them to bill for rounds in the critical care unit (CCU) or ICU.

Although patients no longer need to be unstable, according to CPTs revised definition, the patient must have a critical illness or injury [that] acutely impairs one or more vital organ systems such that the patients survival is jeopardized. The care of such patients involves decision making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple organ system failure, or to prevent further deterioration. And although physicians no longer have to provide constant care to the patient, they still must devote their full attention to the patients care.

In a December 1999 memorandum, Medicare clarified its own guidelines in response to the CPT changes. The Health Care Financing Administration (HCFA) notes that the term unstable is no longer used in the CPT definition to describe critically ill or injured patients. The transmittal then goes on to list two new review criteria that must be met in addition to the new CPT guidelines for critical care claims:

Clinical condition. There is a high probability of sudden, clinically significant or life threatening deterioration in the patients condition that requires the highest level of physician preparedness to intervene urgently.

Treatment. Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of or failure to initiate these interventions on an urgent basis likely would result in sudden, clinically significant or life threatening deterioration in the patients condition.

In addition, while noting that CPT 2000 eliminated the requirement for constant attention as a prerequisite for use of critical care codes, the transmittal also reminds providers that, according to the new CPT description, The physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time. It goes on to state that, according to Medicare, The deletion of the requirement for constant attention is editorial, e.g., the intent of the full attention requirement is the same as the constant attention requirement.

This means that the care being provided must be at such a crisis level that the physician must devote his or her full time and attention to that one patient. In other words, he or she cant see other patients during the critical care time being claimed. For example, if a surgeon documents that from 11:30 a.m. to 1:00 p.m. critical care time was provided to a patient, then care could not be provided to other patients during that time. Auditors will examine the documentation in the physicians charts closely to see if he or she was seeing other patients.

Medical Necessity Is Critical

According to the HCFA memorandum, claims for critical care services should be denied if the services are not reasonable and medically necessary. If the services are reasonable and medically necessary but they do not meet the criteria for critical care services, then the services should be re-coded as another appropriate E/M service (e.g., hospital visit).

It goes on to note that: Providing medical care to a critically ill patient should not be automatically determined to be a critical care service for the sole reason that the patient is critically ill. The physician service must be medically necessary and meet the definition of critical care services as described previously in order to be considered covered.

What this amounts to is that although the CPT and HCFA changes have been interpreted by some surgeons as a green light to bill a lot of critical care, little has really changed, Fletcher says. For example, she notes that under the new guidelines, surgeons still cant bill critical care for ICU rounding visits, which are unlikely to meet the time requirements for critical care.

Patient care that does not meet all the criteria for critical care should be reported using the appropriate E/M codes (e.g., subsequent hospital visit codes 99231-99233, or inpatient consultation codes 99251-99255) depending on the level of service provided.

According to Fletcher, one way to determine whether the services provided to a critically ill patient are subsequent hospital visits or critical care is to ask yourself this question: Does the physician need to be there right now? If the answer is yes, billing for critical care may be appropriate. If the answer is no, a subsequent hospital care code should be used.

Time Spent With Family Now Occasionally Billable

The most noteworthy change for surgeons, says Kathleen Mueller, RN, CPC, CCS-P, a coding and reimbursement specialist in Lenzburg, Ill., is that Medicare has clarified that physicians may include time spent with the patients family to get patients history or discuss treatment when calculating critical care time. However, this applies only if:

The patient is incompetent to provide information;
The patient is unable to provide information; and
The discussion with the family is absolutely necessary for the physician to make a decision on care.

These conditions must be documented in the physicians daily progress note, which, Medicare stresses, must link the family discussion to a specific treatment issue and explain why the discussion was necessary on that day. All other family discussions, no matter how lengthy, may not be counted towards critical care time. Examples of family discussions that do not meet the appropriate criteria include regular or periodic updates of the patients condition, emotional support for the family, and answering questions regarding the patients condition (only questions related to decision-making regarding treatment, as described above, may be counted toward critical care). Telephone calls to family members and surrogate decision makers must meet the same conditions as face-to-face meetings.

Time-based Codes

Critical care is a time-based E/M service, which means that the amount of time spent with the patient should be monitored and documented carefully. Although CPT 2000 did change the time description for 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), the change has no practical effect, says Laura Siniscalchi, RRS, CCS, CCS-P, the education coordinator at Beth Israel Deaconess Medical Center in Boston. The 1999 description said first hour while in 2000, the description reads first 30-74 minutes. Since the add-on code is for each additional 30 minutes and CPTs rules say that at least half the time must pass before time-based codes may be used, 99291 always included critical care through 74 minutes.

Siniscalchi adds that one significant change to the CPT timetable for critical care codes in 2000 is the instruction that for any critical care time less than 30 minutes, appropriate E/M codes should be used. Previously, CPT required surgeons to use 99232 or 99233 (subsequent hospital care), which may have been confusing if these codes were inappropriate for a particular situation (e.g., an admittal).

As it now stands, the first hour of critical care services is billed 99291. The next half hour (75-89 minutes) would be billed 99292 (each additional 30 minutes [list separately in addition to code for primary service]).

99291: 30-74 minutes
99291 and 99292: 75-104 minutes
99291 and 99292 (2 units): 105-134 minutes
99291 and 99292 (3 units): 135-164 minutes
99291 and 99292 (4 units): 165-194 minutes

Note: If critical care lasts less than 30 minutes, you cant bill with critical care codes but must use another appropriate E/M code.

At first glance, defining an hour as 30 to 74 minutes may seem strange, but it is a result of the fact that whatever the period listed in the code, if half that time is documented, Medicare considers the requirement met. In other words, if a surgeon documents spending 32 minutes with a patient, an hour of critical care time using code 99291 may be charged (assuming all the other criteria have been met). If the surgeon sees the patient for more than an hour, another 30 minutes can be billed once the 75 minute point has been documented, and so on.

If the physician sees the patient twice that day and provides and documents critical care in both sessions (i.e., critical care was ongoing throughout the day in separate sessions), all time during that day (both sessions) should be rolled into a total critical care time. For example, if a surgeon sees a patient at 10:00 a.m. and provides (and documents) one hour of critical care, then sees the patient again at 2:00 p.m. and provides a second hour, then coding for that day would be 99291 and two units of 99292.

On the other hand, if the surgeon sees a patient at 10 a.m. and provides normal care and later, the patient requires critical care, then the time for both E/M services would be separately coded.

Documenting From and To times is recommended to facilitate and speed up payment, Fletcher says, adding that military or universal times should be noted (e.g., 12:04-13:17).