Internal Medicine Coding Alert

Question: I am constantly debating with one of the internists in our practice about what specific services qualify for critical care because the CPT/Medicare definition is so vague. Can you give us a complete list?

Montana Subscriber

Answer: The CPT manual states that critical care services include but are not limited to the treatment or prevention or further deterioration of central nervous system failure; circulatory failure; shock-like conditions; renal, hepatic, metabolic or respiratory failure; postoperative complication; or overwhelming infection. Critical care services are reported with 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30 to 74 minutes) and 99292 (critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes).

One carrier, Blue Cross Blue Shield of North Dakota, has issued what it refers to as quick guidelines for critical care documentation and coding, which attempt to list some of the reasons or conditions that are examined when determining the status of a patient. Although the guidelines specifically apply to Alaska, Arizona, Colorado, Hawaii, Nevada, North Dakota, Oregon, South Dakota, Washington and Wyoming, they may provide some help to internists in other states as well.

Three of the many critical care scenarios addressed by these guidelines include the following:

When an unstable patient is newly admitted to the critical care unit, that instability can be identified by the mode of treatment that the patient will receive or is being started. Examples include the initiation of vasopressors (i.e., dopamine, dobutamine, volume expanders like plasmanate, hespan or albumin, or normal saline bolus to increase the blood pressure). Other examples include the initiation of the patient on nitroprusside (Nipride) for the immediate reduction of patients in hypertensive crisis or a nitroglycerine drip to relieve chest pain or to decrease cardiac preload.

When a patient is transferred to the critical care unit from another hospital bed for a new condition that requires continuous monitoring or initiation of ventilator care. A new set or change of orders (such as new IVs, IV drips, laboratory work, electrocardiogram, ABG, x-ray) reflecting the new status of the patient would be expected. Specific examples of new orders include the insertion of a Swan Ganz catheter and monitoring hemodynamically with cardiac output, and the insertion of a temporary transvenous pacemaker or application of a transcutaneous pacemaker for symptomatic heartblock.

When a patient in the critical care unit experiences a sudden change in respiratory status requiring the patient to be intubated or requiring aggressive respiratory intervention; or a newly intubated patient who needs ventilator adjustments and other treatment modalities.

A complete copy of these guidelines is available in the March 1999 Medicare Part B Bulletin for Blue Cross Blue Shield of North Dakota, which can be accessed online at www.bcbsnd.com/medweb.

Note: Glenn Littenberg, MD, FACP, a gastroenterologist in Pasadena, Calif., and a member of the American Medical Associations CPT editorial panel; Jim Stephenson, CPC, billing manager for Premium Medical Management Inc., a multispecialty physician group practice in Elyria, Ohio; and Susan Callaway-Stradley, CPC, CSS-P, an independent coding consultant and educator in North Augusta, S.C., provided information for the answers to these Reader Questions.