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Neurology & Pain Management Coding Alert

Reader Question:

Choosing 99291 Leads to Better Reimbursement

Published on Fri Jun 18, 2004

Question: Are there any advantages to choosing critical care codes rather than standard E/M codes? For instance, if I provide t-PA for a stroke patient, am I better off selecting critical care than initial inpatient care codes?

Pennsylvania Subscriber

Answer: You may be better off choosing critical care codes, but only if the service meets the documentation requirements to report 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]).

As a rule, critical care reimburses at a higher rate than other E/M services. In your state (Pennsylvania), for instance, HGS Administrators pays about $256 for 99291. The same insurer pays about 20 percent less for the highest-level initial inpatient care code, 99223 (Initial hospital care, per day, for the evaluation and management of a patient ... high severity). Before selecting critical care, however, you must be sure that your service meets the following criteria:

  • CPT defines a critical illness or injury as one that impairs one or more vital organ systems. This creates a high probability of imminent or life-threatening deterioration in the patient's condition. Astroke patient requiring t-PA could meet this definition, but you must document the severity of the problem to justify critical care.
  • In critical care, the physician treats single or multiple vital organ system failure(s) and/or prevents further life-threatening deterioration of the patient's condition. The physician must continue these life-sustaining services for a minimum of 30 minutes to qualify for 99291. You should document all time carefully.

  • Although the physician does not usually provide these services in the office for an extended time, he may perform them until the patient can be transported to a hospital or critical care unit, or the neurologist may provide critical care in the hospital setting. A patient does not have to be housed in a critical care unit to qualify for critical care as defined by CPT.

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