Neurology & Pain Management Coding Alert

Your neurologist could be involved in critical care treatment at any time. Just as she needs to be prepared for such an event, you also need to know the rules of reporting critical care, or you risk seeing the denials pour in.

By following three expert tips, you'll ensure that you're not overusing -- or under-using -- the critical care codes.

Before you consider reporting 99291 (Critical care,evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (... each additional 30 minutes [List separately in addition to code for primary procedure]), you need to ensure your neurologist's service meets three criteria.

First, the patient must meet the definition of critically ill or critically injured. A critical illness or injury is defined by a high probability of imminent or life-threatening deterioration in the patient's condition. In addition "the illness or injury severely impairs one or more vital organ systems, such as central nervous system failure,"says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA,CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

Secondly, the physician must perform critical care services. Critical care requires high-complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure, and/or to prevent further life-threatening deterioration of the patient's condition. Therefore, a non-physician practitioner, such as a nurse practitioner, cannot perform critical care services.

Finally, your neurologist must have spent a cumulative time of at least 30 minutes on a given date of service on the critical care services. Time can be continuous or intermittent on the date of service and must be clearly documented in the medical record.

There are two extremely important components you'll need to determine to report a critical care code: the time your physician spent on tasks directly related to the individual patient's care, and what those tasks were.

Time is the most crucial component when coding critical care. "Time must always be documented," says Denae Merrill, CPC, a coding professional in Saginaw, Mich.

When coding critical care, you'll use 99291 for the first 74 minutes of critical care, and +99292 for additional time beyond 74 minutes.

Make sure your neurologist accurately documents the critical care services he performed and how long each service took. "The more details the better, especially when other, separately reportable services are performed," Merrill says.

"I've seen Medicare audits that downcode service to 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) because of inadequate documentation," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network.

Skip some services: You should deduct the time spent performing these activities from overall critical care time:

• CPR
• endotracheal intubation
• chest tube/central line insertion
• ultrasound interpretation
• laceration/orthopedic repairs
• endoscopy or colonoscopy.

You should also deduct teaching time aside from the critical care and time spent speaking with people other than the patient that does not directly bear on the patient's medical care.

Pitfall: Remember that place of service is not always a factor in critical care coding. "Just because you're in the Emergency Department does not mean you're performing critical care," Cobuzzi says. Likewise, just because the patient is in the intensive or critical care unit does not automatically mean that your neurologist's services would be critical care services.

As a general guideline, "any services performed that are not listed in the critical care service description as inclusive can be reported separately," says Marianne Wink, RHIT, CPC, ACS-EM, with the University of Rochester Medical Center in Rochester, N.Y.

CPT section guidelines for Critical Care Services do indicate a number of services that CPT bundles with critical care.

Some common services that are bundled by CPT include, but are not limited to:

interpretation of cardiac output measurements

• x-rays
• pulse oximetry
• blood gases
• tests that store information digitally (for instance,ECGs, blood pressures, hematologic data)
• gastric intubation
• temporary transcutaneous pacing
• ventilatory management
• vascular access procedures (except most of the central line codes).

According to the Correct Coding Initiative (CCI), Medicare also considers the following codes to be components or column 2 codes of the comprehensive critical care code (99291):

• 90846 and 90847 -- Family psychotherapy
• 92531 and 92534 -- Nystagmus testing
• 95831 ��" 95834 -- Manual muscle testing
• 95851 and 95852 -- Range of motion measurements.

These edits carry the "0" bundling edit indicator,which means you cannot bypass the edit with a modifier.

Example: Your neurologist performed manual muscle testing to evaluate a critically ill patient and you also reported critical care services on the same day.Medicare would allow the critical care code, but would deny the manual muscle testing code because of bundling, most likely with this explanation: "Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed."

Best bet: Check both CPT's guidelines in the E/M/ Critical Care Services section and the current CCI edits foradditional services you cannot report along with 99291 and +99292.