Increase Pay Up by Properly Using Critical Care Codes
Published on Sat Apr 01, 2000
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 [...]
