General Surgery Coding Alert

Question: Are there any advantages to choosing critical care codes rather than high-paying E/M codes? For instance, the surgeon spends an hour at the bedside of a vehicle-accident trauma patient who is too unstable to undergo surgery. Should we choose 99291 or 99223? Pennsylvania Subscriber Answer: You may be better off choosing critical care codes, but only if the service meets the documentation requirements to report 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]). As a rule, critical care reimburses at a higher rate than other E/M services. In your state (Pennsylvania), for instance, HGS Administrators pays about $256 for 99291. The same insurer pays about 20 percent less for the highest-level initial inpatient care code, 99223 (Initial hospital care, per day, for the evaluation and management of a patient ... problems of high severity).

Before selecting critical care, however, you must be sure that your service meets the following criteria:

CPT defines a critical illness or injury as one that impairs one or more vital organ systems. This creates a high probability of imminent or life-threatening deterioration in the patient's condition. Avehicle-accident trauma patient could certainly meet this definition, but you must document the severity of the problem(s) to justify reporting 99291/99292. In critical care, the physician treats single or multiple vital organ system failure(s) and/or prevents further life-threatening deterioration of the patient's condition. The physician must continue these life-sustaining services for a minimum of 30 minutes to qualify for 99291 (a requirement that you've met in this case). You should carefully document all time your surgeon spends with the patient, including start and stop times, if possible.

Although the physician does not usually provide these services in the office for an extended time, he may perform them until the patient can be transported to a hospital or critical care unit, or the surgeon may provide critical care in the hospital setting (as in your case). A patient does not have to be housed in a critical care unit to qualify for critical care as defined by CPT