Medicare Compliance & Reimbursement

Medicare clears up counseling, concurrent care rules. If coders can learn to spot critical care indicators, and doctors are diligent about documenting encounter specifics, you can capture critical care each time the physician provides it. To help coders with this process, CMS released transmittal 1530 on June 6. This document puts all critical care coding guidance in one easy-to-access place, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania. The transmittal, effective July 7, makes especially clear points on documenting family counseling time and coding for concurrent critical care. Keep it handy when you’re coding for 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 ( … each additional 30 minutes). Use CMS ‘Approved’ List The transmittal spells out exactly what interactions with the patient’s family you can count toward overall critical care time, Pohlig confirms. According to the transmittal, "CPT codes 99291 and 99292 include pre- and post-service work. Routine daily updates or reports to family members and/or surrogates are considered part of this (included) service." So if the physician meets for three minutes with a patient’s wife to give her an update, don’t count this as critical care time. Exception: When the patient is unable or incompetent to give a medical history or make treatment decisions, you can count time spent consulting with the family toward critical care. You can also include time spent discussing treatment decisions, if the physician has to ask a family member for patient information. You’ll need to be sure to document the family counseling time properly, Pohlig warns. When recording family counseling time for critical care, the transmittal states that the provider must document the following: • that "the patient is unable or incompetent to participate in giving history and/or making treatment decisions; • the necessity to have the discussion (e.g., ‘no other source was available to obtain a history’ or ‘because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family’); • medically necessary treatment decisions for which the discussion was needed; and • a summary in the medical record that supports the medical necessity of the discussion." Show Physicians the Value of Documentation The physician also needs to be diligent about documenting the other critical care components. Often, the physician does not provide enough information on encounter forms to justify critical care coding. Bottom line: To report 99291, the physician needs to spend a minimum of 30 minutes providing critical care to the patient. If the physician performs activities that count toward that time, but does not include them in the documented time, then appropriately coding critical [...]