Medicare Compliance & Reimbursement

Your physician documents that a patient suffered a serious "critical" injury and underwent major surgery. You should report a critical care code along with the procedure code because the patient was critically ill, correct? Wrong.

You must meet all three of the following key criteria to report critical care services:

1. The patient must meet the definition of critically ill or critically injured. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition.

2. The physician must perform critical care services. Critical care requires high-complexity decision-making to assess, manipulate and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient's condition.

3. Critical care services require a cumulative time of at least 30 minutes on a given date of service. Time can be continuous or intermittent on the date of service and must be clearly documented in the medical record.

Reality: If you report critical care codes inappropriately, the denials will pile up. Make sure you're confident when "critical" cases cross your desk by following these expert tips.

Before you use 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]), you should review how CPT defines a critical care patient.

According to CPT, the patient must have "a critical illness or injury [that] acutely impairs one or more vital organ systems."

Here's the catch: This condition is one of the most common reasons that many services often do not fit the critical care definition. Even very complex surgeries with major complications may not lead to a physician caring for a life-threatening failure of an organ system such as the heart or lungs.

Example: While your physician is performing a transurethral resection of the prostate (TURP), the patient has a heart attack. The physician calls in a cardiologist who performs critical care treatment. Even if the lifesaving measures qualify for critical care, the cardiologist, not your physician, will report the critical care codes.

Your other option: If your physician's services do not meet the criteria for critical care services, you should not report 99291 or 99292. "If all criteria are not met to report a critical care code, the physician would report the appropriate E/M visit and service level documented in the medical record" (such as subsequent hospital care codes, 99231-99233; or inpatient consultation codes, 99251-99255), says Cindy Parman, CPC, CPC-H, RCC, co-founder of Coding Strategies Inc. in Powder Springs, GA.

Just because your physician provides care to a critically ill patient, you shouldn't automatically assume you can code his services using critical care codes.

Example: A physician performs a radical nephrectomy, and the patient has complications, such as extensive blood loss, that result in the physician admitting the patient to the intensive care unit (ICU). When the physician later performs rounds and visits the patient in the ICU, you shouldn't assume this is critical care because he may not be providing critical care services to the patient (the patient care may only be related to the standard post-op care following urological surgery and not necessarily the patient's critical illness) or meet the time requirements for critical care.

Note: A patient does not have to be in an ICU to be critically ill, and similarly, not every patient in an ICU is critically ill, Parman says.

Be clear: The word "stable" is often confusing for physicians and coders alike, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "The patient may be 'stable' due to the interventions provided. Remove the intervention, and the patient may severely decline."

The critical care codes are time-based, so when you do need to report critical care codes look at your physician's documentation to determine which code you should report. For the first 30 to 74 minutes of critical care your physician provides, report 99291.

For each additional 30 minutes, report 99292. If the physician spends less than 30 minutes providing critical care to the patient, you have to choose another appropriate E/M code. See the chart below for more on when to report 99291 versus 99292.

Remember: Time that your physician spends performing separately reportable procedures does not count as critical care. And when reporting critical care, the physician's critical care time should not overlap with critical care time reported by another physician on the same day.

"If multiple physicians participate in the same critical care service, only one physician may report the critical care time. Generally, this is the physician responsible for orders and patient care," Parman says.

Note: For critical care time lasting beyond the examples listed here, simply add one unit of 99292 for each additional 30 minutes, in the same manner illustrated in the chart.