Neurology & Pain Management Coding Alert

Critical care services have been redefined in CPT 2001. These codes (99291 and 99292) can be used only when the neurology patient is critically ill. According to the AMA, the further text revisions accepted for CPT 2001 were made to offer guidance to delineate when it is appropriate to report these codes as opposed to emergency services and other high-level E/M services.

These revisions will benefit neurology coders who previously had to fight with insurance companies to convince them that critical care services were provided and should be reimbursed. For example, problems often resulted because neurologists primarily deal with only one vital organ system, but payers felt that more than one system had to be in danger before critical care codes were appropriate. This has been cleared up in CPT 2001, which clearly states that one vital organ system can be in danger.

Critical Care Guidelines

Bryan Sorenson, senior administrator, University of Maryland Medical Center, department of neurology, reports that if the patient is neurologically unstable and the neurologist is working to stabilize his or her condition, it is appropriate to bill critical care codes.

He reminds neurologists that one of the key factors in gaining reimbursement is thorough documentation.

According to CPT 2001, documentation of critical care services should include the following:

Time spent in work directly related to the patients care whether at the bedside or on the floor or unit reviewing test results or imaging studies, discussing the patients care with medical staff, and documenting critical care services in the medical record.

When the patient is unable or clinically incompetent to participate in discussions, time spent on the floor or unit meeting with family members or surrogate decision makers obtaining a medical history, reviewing patients condition or prognosis, or discussing treatment or limitation(s) of treatment provided the conversation bears directly on the management of the patient.

Critical Care Code Changes for 2001

The introduction to the critical care codes in the CPT 2001 manual has been altered to include certain restrictions. The new language lists several elements that are key to understanding when billing for these services is appropriate. They include:

1. Critical Injury. CPT 2000 defined critical care as the delivery of care for a critically ill or injured patient. CPT 2001 inserts the word critically before injured, so there is no confusion about this: The patient must be critically injured.

2. Life Threatening. CPT 2000 provided that a critical illness or injury impairs one or more organ systems where the patients survival is jeopardized. CPT 2001 honed this language to state that the organ system impairment must include a high probability of imminent or life-threatening deterioration in his or her condition. For instance, a vital organ system failure could include, but is not limited to, a central nervous system failure, shock, and/or respiratory failure.

Neil A. Busis, M.D., Chief of the Division of Neurology and Director of the Neurodiagnostic Laboratory at the University of Pittsburgh Medical Center ar Shadyside gives the following example of a life-threatening situation in which the coding has not changed from CPT 2000 to 2001. This is because the administration of t-PA for the treatment of a stroke still requires the constant attendance of the physician: Example: A patient has a stroke (436), and the neurologist decides to give an infusion of t-PA code 37195 (thrombolysis, cerebral, by intravenous infusion). The hospital bills for the infusion and the neurologist for the critical care codes for the E/M services provided to administer the t-PA, including review of tests to decide if the medication is appropriate, observe the infusion administered, and monitor the patient.

He also gives an example that has changed from CPT 2000 to 2001: A patient is brought into the emergency room for status epilepticus with psychomotor seizures (345.7). The neurologist performs critical care services to control the seizures, which will cause permanent brain damage and possibly death if not stopped. He or she is treated with anticonvulsants to stop the seizures, and may even have to be ventilated and have his or her blood pressure and metabolism stabilized.

Prior to 2001, the neurologist would have had problems using the critical care codes for this treatment because only one vital system was in danger of failing (the central nervous system). Critical care was considered by carriers to involve more than one vital organ system failure. But in 2001, it has been clarified that critical care can involve treating one vital organ system failure.

For either example, the neurologist bills 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) if care did not go beyond 74 minutes and 99292 ( each additional 30 minutes) if it did.

3. Illness and Treatment. The following was added in CPT 2001: Providing medical care to a critically ill, injured, or postoperative patient qualifies as a critical care service only if both the illness or injury and the treatment provided meet the requirements in numbers 1 and 2 above. With CPT 2000, neurologists might have a critical care patient in the ICU but give routine care using these codes. With 2001, neurologists can only provide treatment that qualifies as critical care in order to bill these.

For example, if a patient had a seizure (780.39) and was in stable condition but in the critical care unit, it might have been considered critical care with CPT 2000. But with CPT 2001, he or she would have to be in more of a severe condition such as having status epilepticus (345.3 a string of seizures where in between the seizures, the patient never fully recovers consciousness). In this situation, the neurologist needs to be at the patients bedside to decide what treatments are to be used to stop the seizures, what diagnostic tests are to be performed, and to ensure that the patient does not injure him- or herself.

4. Other E/M Services. Under CPT 2001, the physician may provide other evaluation and management (E/M) services in addition to critical care on the same date. For example, a neurologist may admit a patient to the hospital (99221-99223) in the morning, and later in the day the patient may develop a condition that warrants use of the critical care codes and those can be billed as well. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be attached to the admit code so reimbursement will be received for both.

5. Time Spent With Family. As in CPT 2000, the neurologist can bill critical care codes for time spent discussing treatment with the family when the patient is unable to. This time must be spent on the floor or unit. A new phrase, however, requires that these codes be used only for discussions with the family when the conversation bears directly on the management of the patient.

Busis gives the example of a patient who is in a coma (780.01). In this case the neurologist needs to discuss the management of the patient with the family because he or she is unconscious. But the documentation must show that the discussions directly affected the management of the patient as opposed to CPT 2000, in which the discussions had to relate to medical decision-making.