Medicare Compliance & Reimbursement

Hint: Know the basic requirements for coding critical care.

Once you’ve answered the quiz questions, compare your answers with the ones provided below:

Answer 1: You need two of the three key E/M components — history, exam, and medical decision-making — to report subsequent hospital care services. Moreover, those two components must be fully documented and match the level of the E/M code you select to justify the use of each subsequent care code. If there is little or no documentation, then you need to change the code.

Typically, physicians document the exam and medical decision-making components to fulfill the CPT^® E/M requirement. If you perform and document high-complexity medical decision-making along with a detailed exam, this supports a 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components...).

Tip: If your practice routinely bills the same subsequent hospital care code, you should perform a chart review to ensure you’re accurately coding the visits, says Terri Orcala of Orcala Billing in Kansas City, Missouri.

Answer 2: 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)) occur when a physician or other qualified healthcare professional directly provides medical services for a critically ill or critically injured patient. As always, the documentation must support the necessity of the critical care service.

To qualify for critical care, a service must meet the following provisions:

• The patient must be critically ill/injured — have vital organ failure or a life-threatening health condition.
• The physician must perform the critical care services, including using high-complexity decision making to assess, manipulate, and support vital system functions to treat vital organ system failure or to prevent further life-threatening conditions.
• All critical care services must last at least 30 minutes on a given date of service. The time can be continuous or intermittent. But, for any given period of time the physician spends providing critical care services for a patient, he cannot provide services to any other patient during the same period of time.

Bottom line: You cannot report time the physician spends in activities that occur outside of the unit or off the floor as critical care since the physician is not immediately available to the patient. Additionally, you may not report time spent in activities that do not directly contribute to the treatment of the patient as critical care, even if they are performed in the critical care unit.

Answer 3: There are two main differences between 99490 (Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month ...) and 99491(Chronic care management services, provided personally by a physician or other qualified healthcare professional, at least 30 minutes of physician or other qualified healthcare professional time, per calendar month …) that will impact which code you choose. One relates to the important issue of time in CCM coding, and the other focuses on who provides the service.

“The first difference between the codes that you should remember is the time requirement,” Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania, reminds coders. For 99491, you must be able to document that the chronic care management took at least 30 minutes. For 99490, the descriptor stipulates that the time spent in the management services must be “20 minutes or more.”

“The second difference is that 99490 is for chronic case management directed by a physician, whereas 99491 is care management personally provided by the physician,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, noting that the provider can also be a qualified healthcare professional (QHP) per the CPT^® descriptors.

Resource: Find more in-depth Medicare explanations on E/M documentation at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf.