Neurology & Pain Management Coding Alert

Of the four categories, critical care requires the highest level of physician involvement, but it also provides the highest reimbursement. Documentation requirements for critical care are exacting, and only a minority of patients qualify for critical care services.

According to CPT, "Critical care is the direct delivery by a physician of medical care for a critically ill or critically injured patient." CPT further specifies that a critical illness or injury acutely impairs one or more vital organ systems such that the patient's survival is jeopardized. The care of such patients involves decision making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple organ system failure, or to prevent further deterioration.

Stroke patients requiring t-PA meet the criteria for critical care if there is "a high probability of sudden, clinically significant or life-threatening deterioration in the patient's condition that requires the highest level of physician preparedness to intervene urgently," explains Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting in Manassas, Va., citing CMS guidelines. She notes that intravenous t-PA administration in stroke victims has a 12 percent risk of fatal cranial hemorrhage, and CMS instructions to Medicare providers specifically indicate, "Critical care services require direct personal management by the physician. They are life- and organ-supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis likely would result in sudden, clinically significant or life-threatening deterioration in the patient's condition."

Although critical care is generally provided in a critical or intensive care unit, it need not be. By the same token, however, not all patients in the critical or intensive care unit warrant use of critical care services: As long as the requirements of critical care are met, 99291-99292 may be reported, regardless of location.

Critical care codes are time-based and include only specific services. Therefore, physicians reporting 99291-99292 must provide thorough and accurate documentation outlining the services provided and the amount of time spent providing them.

To claim 99291 the physician must document a minimum of 30 minutes. If fewer than 30 minutes of critical care are provided, the service should be reported using another appropriate E/M service code (as discussed elsewhere in this article). Only one unit of 99291 should be reported per claim. Each additional 30 minutes of critical care beyond the first 74 minutes is reported using add-on code 99292, as follows, advises Linda Laghab, CPC, coding department manager for Pediatric Management Group at Children's Hospital, Los Angeles:

For example, if the neurologist spends 45 minutes at the patient's bedside providing critical care and t-PA administration, the correct coding is 99291, 37195. If he or she spends one hour, 50 minutes providing the same services, proper coding is 99291, 99292, 37195 and so on.

Note that critical care time need not be continuous, but it is "best practice" to record all start and stop times. At a minimum, an estimated time should be explicitly noted in the documentation and included when filing the claim. Documentation reading "critical care > 30 minutes," for example, is generally too vague.

Time counted toward critical care must be spent engaged in work directly related to the individual patient's care, says Roger P. Holland MD, PhD, FAAFP, physician reimbursement specialist and president of Utilization PRO Inc. "If time is not legibly and unequivocally documented, the claim will be subject to recoding or denial," he says. Time involved performing separately billable procedures should not be counted as critical care.

Some carriers have too narrowly defined the requirement that the physician provide his or her "full attention" to mean that only time spent at the patient's bedside may qualify as critical care. This is incorrect: Time spent at the nursing station, on the floor reviewing test results or imaging studies, discussing the critically ill patient's care with other medical staff or family, and documenting critical care services may be reported as critical care. Time spent simply being present in the patient's room or at the station in case a problem develops, or overseeing intermittent monitoring but otherwise engaged in activity not directly related to the patient's critical care does not qualify as critical care.

In addition, Medicare has clarified that physicians may include time with the patient's family to obtain the patient's history or discuss treatment when:

1. The patient is incompetent to provide information,
2. The patient is unable to provide information, and
3. The discussion with the family is absolutely necessary for the physician to decide on care.

Telephone calls to family members and surrogate decision-makers must meet the same conditions (above) as face-to-face meetings, Holland advises.

All three criteria must be documented in the medical record, which "must link the family discussion to a specific treatment issue and explain why the discussion was necessary on that day," according to CMS. All other family discussions (e.g., regular or periodic updates of the patient's condition, emotional support for the family, and answering questions regarding the patient's condition) regardless of length may not be counted towards critical care time.

Note: Look to the August 2002 Neurology Coding Alert information on reporting prolonged care services, initial inpatient care and initial and follow-up consultation codes for t-PA administration.