Neurology & Pain Management Coding Alert

Without a critical illness or injury, you can forget about 99291/99292.

One of the most difficult decisions to make when coding evaluation and management (E/M) services concerns critical care.

And whether to choose 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]) for those services is a critical decision.

Fallout: Code for critical care when it didn't occur, and auditors could be heading your way. If you neglect 99291/99292 when you could have used them, however, you'll be costing the practice deserved reimbursement.

Learn the ropes of 99291/99291 coding with this critical care crash course Q&A, and pass it around to anyone in the practice who might have to make this critical coding decision.

Q: What does "critically ill or injured" mean?

A: CPT® states that a patient must be critically ill or injured in order to use critical care codes so you'll need to be sure you know what that means before tackling a critical care claim.

CPT® 2016 "states that 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" if the patient does not receive immediate care, explains Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Mich.

Some patients that your provider might provide critical care services include those who suffer:

Acute brain injury (S06.-, Intracranial injury)

Massive cerebral hemorrhage (I60.-, Nontraumatic subarachnoid hemorrhage through I66.-, Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction)

Status epilepticus (G40.-, Epilepsy and recurrent seizures, often with a sixth character of 1)

Respiratory failure in Guillain-Barre' Syndrome (J96.0-, Acute respiratory failure, as well as G65.0, Sequelae of Guillain-Barre syndrome [for the sequelae of Guillain-Barre syndrome]).

Q: A patient's critically ill. The physician prevents further deterio­ration. That's critical care, right?

A: Definitely maybe. The clock matters when considering 99291/99292.

As the code descriptor states, the provider must perform at least 30 minutes of critical care before you can consider 99291. When the physician provides less than 30 minutes of care - even if she's stabilizing a critically ill patient - you cannot choose critical care codes.

Recourse: If the total time spent providing critical care services doesn't last at least 30 minutes, leave 99291 alone and choose the appropriate evaluation and management (E/M) code based on the encounter notes. For example, if the care occurred in the emergency department (ED), you might be able to choose 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity...) - if the encounter notes justify this high-level E/M code.

Q: Does documentation matter on critical care claims?

A: Yes, absolutely. In fact, the critical care provider must document that she performed critical care in the encounter notes you'll file with the claim.

A simple note such as "provided 33 minutes of critical care for patient X" would suffice, but make sure you have that documentation on the claim. Without documentation from the physician that specifies exactly how much critical care time she provided, your 99291/99292 claims won't fly.

Q: In which settings can a physician perform critical care?

A: Critical care can occur in any setting, says Sharon Richardson, RN, compliance officer for E/M services at Emergency Groups' Office in San Dimas, Calif. The ED or intensive care unit (ICU) might see the lion's share of critical care encounters, but they can occur anywhere.

Nuts and bolts: "If the patient is critical and the physician provides 30 or more minutes of critical care services, they can bill for critical care," explains Richardson.

Still, Richardson says most critical care occurs in a hospital setting, and it could be in any area including:

• Med-surg unit
• Operating room (OR)
• Radiology unit
• Critical care unit (CCU) or
• Observation unit.

Critical care in an office setting is possible, but not likely. Usually, if a patient is critically ill in the office, the provider will call 911 while caring for the patient. These are instances in which the physician might provide "critical care," but doesn't reach the 30-minute threshold.

Exception: "If the physician follows the patient to the hospital and continues treatment, the combined times could support critical care," Richardson says.

Q: Does critical care need to be continuous?

A: No. The physician could, for example, provide 35 minutes of critical care in the morning, then 23 more in the afternoon, confirms Richardson.

Caveat: You'll need to be absolutely sure that the physician provided critical care for the entire time you are coding for - and that the physician documented this fact in the medical record.