Internal Medicine Coding Alert

Physician 'preventing further deterioration' keys valid critical care claims.

What do critical care services need to contain to withstand scrutiny? The service has to meet CPT's time parameters, patient condition, and physician actions requirements.

Checking encounter notes for these items just got easier thanks to solutions on critical care's "who, what, and where?"

Who Qualifies for Critical Care?

 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]), the internist must be treating a patient that is critically ill or injured, confirms Rebecca Parker MD, FACEP, president of Team Parker LLC, a coding, billing, and compliance consulting firm in Lakewood, Ill.

CPT classifies a critical illness or injury as acute damage to one or more of the patient's vital organ systems, Parker explains.

Critical care also involves high-complexity medical decision making in assessing and supporting those vital organ systems to prevent the patient from getting worse, says Shelley Bellm, CPC, coder at Colorado Mountain Medical.

Critical care "requires the highest level of physician preparedness to intervene urgently. Failure to intervene would likely result in clinically significant or life-threatening deterioration," explained Kenny Engel, CPC, coding coordinator with Advanced Healthcare in Germantown, Wis., during his recent Coding Institute audioconference "Critical Care Reporting" (www.codinginstitute.com).

Conditions that might warrant critical care service include the following, writes Stephen R. Levinson, MD:

 • failure of the central nervous, circulatory, or renal systems
 • shock
 • hepatatic, metabolic, or respiratory failure.

Remember: If the patient is suffering from one or more of the above conditions, then your internist's service might qualify as critical care.

Caution: Before you can consider 99291, the treatment time must exceed 30 minutes. This time parameter is inflexible, according to Levinson.

"If the physician spends less than 30 minutes of critical care time on a particular day, regardless of the severity of patient illness and complexity of decision making and treatment, an appropriate E/M code must be submitted" instead of 99291, Levinson writes in Practical E/M: Documentation and Coding Solutions for Quality Patient Care.

This time does not need to be continuous, says Parker -- but it does need to add up to at least 30 minutes before considering 99291.

What's Included in Critical Care?

 If your internist provides any of the following services during critical care, do not code them separately, as they are included in 99291 and +99292 service. When totaling critical care time, the 2009 CPT manual states that you cannot include these services:

 • interpretation of: cardiac output measurements (93561, 93562); x-rays (71010-71020); pulse oximetry (94760-94762); blood gasses, and information data stored in computers (such as ECGs, blood pressures,  hematologic data [99090])
 • gastric intubation (43752, 91105)
 • temporary transcutaneous pacing (92953)
 • ventilatory management (94002-94004, 94660, 94662);
 • vascular access procedures (36000, 36410, 36415, 36591, 36600).

Report any services the internist performs that are not listed above separately from 99291. Services that are excluded from critical care include: endotracheal intubation, pericardiocentesis, and central venous catheter placement.

Example: Let's say notes indicate a 49-minute session in which the internist provides critical care. During the encounter, the physician performs CPR for 10 minutes, and spends nine minutes performing central venous catheter placement.

In this instance, you'd report 99291 for 40 minutes of critical care, and represent the nine minutes spent placing the catheter as 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older).

Where Can the Internist Provide Critical Care?

Critical care can occur wherever the physician performs critical care on a patient. The ICU/ED setting is not necessary to report 99291 and +99292, says Parker.

When considering critical care codes, focus on the patient's condition and time parameters. Did the internist treat a critically ill or injured patient for at least 30 minutes? If so, he might have provided critical care.

Example: A hospital inpatient patient with emphysema goes into shock and respiratory failure. The internist provides 39 minutes of critical care to the patient at the patient's hospital bed. This is still a critical care service despite the hospital inpatient setting -- provided the patient received "full attention" from the internist for the entire 39 minutes.

Full attention from the physician means that the internist must be at the patient's bedside or on the floor and immediately available to the patient, explained Engel.

For example, if he's reviewing lab test results or discussing the patient with other medical staff in the unit or at a nursing station, he is providing the patient "full attention," said Engel.

If the internist leaves the hospital unit or devotes time to another patient while treating a critically ill patient, this is not "full attention." Carve this time out of your critical care reporting.