Neurology & Pain Management Coding Alert

Are you reporting all separately reimbursable services when coding for critical care? Although critical care bundles a number of procedures and services, it is not "all inclusive," and knowing when to claim separate services will boost both your payments and your coding accuracy.

Critical care includes both physician time spent at the patient's bedside and time spent at the nursing station or the floor reviewing test results or imaging studies. And, you may count time the neurologist spent discussing the critically ill patient's care with his or her family if the patient is unable to provide the information.

You should be sure that documentation "link[s] the family discussion to a specific treatment issue and explain why the discussion was necessary on that day," CMS states. You should not count any other family discussions (e.g., regular or periodic updates of the patient's condition, emotional support for the family, and answering questions about the patient's condition) - regardless of length -toward critical care time.

For example, a patient in extreme shock cannot communicate with the neurologist, who must therefore consult with the family for advice concerning the patient's past medical history, etc., before making any treatment decisions. This time can count as critical care. Later, the patient stabilizes and the physician again sees the family to update them on the patient's condition. This time does not count toward critical care because it is not necessary in the physician's decision-making process. Telephone calls to family members and surrogate decision-makers must meet the same conditions, says Roger P. Holland, MD, PhD, FAAFP, physician reimbursement specialist and president of Utilization PRO Inc.

Although CPT does bundle some procedures to critical care, including ventilator management, gastric intubation and others (see the critical care portion of CPT for a complete list), you may report all other procedures separately. When you report 99291/99292 with other procedures, however, some payers (including Medicare) may require that you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the critical care codes to indicate that the service was "above and beyond the usual pre- and postoperative care."

You may also report critical care on the same day as other E/M services, says Linda Laghab, CPC, coding department manager for Pediatric Management Group at Children's Hospital, Los Angeles. Once again, you must append modifier -25 to the critical care codes.

For example, the neurologist may provide subsequent hospital care (99231-99233) for a trauma patient in the morning. Later in the day, the patient's condition may worsen, requiring that the physician provide an hour of critical care. In this case, report 9923x and 99291-25. You should separate the critical care documentation from any other E/M documentation provided on the same date of service, Laghab says.