General Surgery Coding Alert

Learn the Fine Points of Coding Critical Care

Published on Sat Sep 13, 2003

Get more out of 99291 and 99292

Insufficient physician documentation - not your coding skills - could be jeopardizing reimbursement for your critical care claims when dealing with acute patient conditions such as severe gastrointestinal bleeding (578.9, Hemorrhage of gastrointestinal tract, unspecified).

Tell your doctors about the payment they sacrifice if they don't understand when and how to document critical care, says James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa. - and then help them out with the information below.

'High Probability' Opens Reimbursement Doors

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]) may cover more services than you or your general surgeon thinks it does.

Critical care services include the direct delivery of medical care to a critically ill or injured patient, says Deborah Grider, CPC, CPC-H, CCS-P, CCP, president of Medical Professionals Inc. in Indianapolis. A critical care patient must have the "high probability of imminent or life-threatening deterioration," according to CPT.

But don't overlook the phrase "high probability" - that's what could increase your revenue. A patient doesn't have to be on her deathbed to require these services. The necessary condition is the risk for, not the presence of, instability. "Physicians so often fail to document critical care time on patients whose condition could deteriorate rapidly into a life-threatening situation," says Nettie McFarland, RHIT, CCS-P, at Healthcare Billing Systems Inc. in South Daytona, Fla.

Consider the following example of a general surgeon providing critical care services for a patient with chronic liver disease (571.9). Your physician tells one of her patients who has been having severe gastrointestinal bleeding to meet her in the emergency department (ED) of your local hospital. The bleeding is heavy, and the surgeon cannot immediately identify its origin. Although the patient is technically not unstable, there is an imminent risk, a high probability, of his bleeding out. The physician sees the patient, conducts tests and analyzes results, and consults with other physicians for more than 30 minutes. You should code 99291 and 99292 because the general surgeon is administering critical care.

In this case, the presenting problem - not the final diagnosis or condition - determines the risk factor. The severe bleeding presents the potential for an unstable, high-risk condition, so diagnosing and treating the crisis warrants critical care codes.

Here's a useful rule of thumb for determining critical care status: For you to report critical care, the patient must be on a medication or a treatment regimen that is supporting an organ system, and without that treatment the patient would be unstable, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. This approach will keep you from over-reporting critical care.

Watch Your Documentation

Documentation is the saving grace of critical care payment. Review your documentation completely before using it to support critical care codes, McFarland says.

Check that your documentation covers the site of service, medical necessity, and the services provided, Grider says. Payers are looking for appropriate risk factors, progress, and response to treatment, whether it's positive or negative, she adds.

Tell your physician to document the following:

High-complexity decision-making. Reporting critical care requires this component as indicated by CPT's definition of this service. Two of the three elements determining medical decision-making - number of diagnoses or management options, amount and/or complexity of data to be reviewed, and risk of complications and/or morbidity or mortality - must meet or exceed the CPT definitions to qualify for high complexity.

Revisions of diagnoses. For example, when a patient with gastrointestinal bleeding improves the next day but still requires steady blood draws to monitor blood count, your physician should note this change in status and append any appropriate documentation to the patient's chart.

Critical care time. Your physicians must document time spent rendering critical care on the chart and then date and sign the record. This documentation requirement is crucial because reimbursement for critical care codes depends on time spent by the physician providing care. If the physician doesn't document properly (see below for guidelines on adequate documentation), send the chart back to him and ask him to return it within a reasonable time - for example, four to five days, Blakeman says.

Documentation can show either the total duration of time or indications of start and stop times, Grider says. Be aware, however, that some carriers have issued transmittals requiring that physicians use start and stop times, she adds. Make sure that you check your local carrier's policy for its specific requirements.

Here are four pointers on how to total critical care time accurately:

1. Tell your physician to subtract from the critical care time any additional time he spends on activities that don't directly contribute to the patient's care, including meetings and time spent consoling the family, unless that conversation brings up points relevant to the patient's care, Blakeman says.

The patient must be unable or incompetent to participate in providing information or discussing treatment if the physician counts time with family members or decision-makers toward critical care, Grider adds. And you cannot count any time spent on the telephone with the family as critical care, she says.

2. Refer to the CPT time chart for reporting time spent. The minimum time requirement for critical care codes is 30 minutes. When a patient requires fewer than 30 minutes of critical care, you should report the surgeon's services using an E/M code and include the documented critical care services when assigning a code, Blakeman says. Documenting the need for and use of critical care services demonstrates the risk involved in the E/M case. This may be helpful for supporting your E/M level, but it is not required for reporting other hospital care services (99221-99233).

3. Report 99291 only once per date even if the physician's time spent is not continuous. Critical care time does not have to be consecutive, but it can be cumulative on a given date of service. Physicians should add together interspersed critical time periods and report the sum.

4. Remember that critical care time can occur outside of the intensive care unit (ICU) or ED, as long as the services meet the standard criteria of a "high probability of imminent or life-threatening deterioration." Along the same lines, you should not use critical care codes just because the patient is in the ICU.