Neurology & Pain Management Coding Alert

Payment policy changes for 37195 mean you-ll need to rely on 99291-99292

If your payment for t-PA administration leaves something to be desired, your practice may be inaccurately reporting this service based on correctable misconceptions of critical care codes.

Take stock of these common 99291-99292 pitfalls to make sure you-re not falling prey to critical care no-no-s.
 
Myth #1: Since critical care is the highest level of E/M, you need to satisfy all the E/M elements.

Reality: Actually, 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]) are time-based codes--and if you look carefully at the code descriptor requirements in CPT, you-ll find no specific requirements for history, physical exam and medical decision-making (MDM).

-Most of the codes in the E/M section of CPT have specific key element requirements with regard to history, physical exam, and medical decision-making,- says Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI, an ED billing company in Stoneham, Mass.
 
For example, to report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three 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), you need a comprehensive history, comprehensive physical exam, and high-level MDM--but those requirements aren't present for critical care, Granovsky says. -These are time-based codes that also require a high probability of imminent or life-threatening deterioration in the patient's condition.-

That time must include at least 30 minutes of care, excluding any separately billable procedures the physician performs, such as t-PA administration. To report this service for stroke patients, pair critical care codes with 37195 (Thrombolysis, cerebral, by intravenous infusion).

Reimbursement heads-up: In the 2006 physician fee schedule, 37195 has a -C- status, meaning that individual carriers can determine the reimbursement level. In practical terms this means that many carriers will opt to pay nothing for this code. If you don't want your neurologist giving away his services, you-ll need to properly report critical care codes.

Myth #2: Critical care must take place in the CCU or ICU.

Reality: While physicians usually end up treating critical care patients in the designated critical care unit (CCU) or intensive care unit (ICU), critical care can take place anywhere in the hospital, says Valrie Hall, CCS, with Peak Health Solutions. According to CPT, critical care isn't specific to any location, such as an ICU or CCU. What determines whether you can report 99291 is the patient's critical condition, Hall says.

If necessary, the physician can perform critical care on the surgical floor, in an observation unit, and particularly in the emergency department, Granovsky says.

Myth #3: The physician's time spent with critical care patients must be continuous.

Reality: The time doesn't have to be continuous, but your neurologist must devote the time she does document as critical care exclusively to that patient.

For example, the doctor attends to a stroke patient at the bedside and makes an assessment. The neurologist can count the bedside time as critical care minutes (assuming the service meets all other critical care requirements) but must stop the clock when she leaves, Granovsky says. When she later goes to radiology to review a computed tomography scan for intra-cranial bleeding, the clock should be running again. If all this time adds up to 30 minutes or more, and the doctor designates critical care, you should report the appropriate codes.

What counts: Don't forget that you can include time the neurologist spends talking with the patient's family as critical care. This can be an important element of care because the patient may not be able to communicate independently. However, you can't count the time the neurologist spends -on-call- waiting for changes in the patient's status.

Myth #4: If two physicians simultaneously provide critical care, they can both bill for it.

Reality: Medicare allows only one provider to report critical care at the same time. According to the Part B Reference Manual from April 2002, -Only one physician may bill for a given hour of critical care, even if more than one physician is providing care to a critically ill patient.-

Example: A husband brings his 65-year-old wife to the emergency department claiming she exhibited signs of stroke 20 minutes prior. Both the ED attending physician and the neurologist provide critical care at the same time to this Medicare patient. In this case, only one of the doctors could report 99291.

Whether the billing physician will be the ED doctor or the neurologist may depend on intra-facility agreements more than the actualities of the care. In the above case, you might have one of two scenarios: The neurologist might bill for critical care while the ED physician bills an ED E/M, or the neurologist might bill a consult code while the ED physician bills critical care.