Neurology & Pain Management Coding Alert

How would you like to improve your E/M reimbursement by 50 percent or more when the neurologist attends to a seriously ill or injured patient? It's not as hard as you think. Just four easy steps can teach you when to report critical care instead of office or inpatient visit codes, thereby raising your revenue and improving your coding accuracy.

CPT provides two time-based codes to report critical care: 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]). To apply these codes effectively, you must document that the patient is critically ill or critically injured and therefore requires the direct personal management of and frequent, personal assessment and manipulation by a physician.

A common example of a neurologist using critical care codes occurs when a stroke victim requires t-PA administration, says Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting in Manassas, Va. She says that intravenous administration of t-PA in stroke victims has a 12 percent risk of fatal cranial hemorrhage and requires constant physician attendance. The situation is potentially life-threatening and, if you document it as such, critical care codes are appropriate. "Critical care codes are among the highest-paying evaluation and management services. Payers are going to review such claims with special scrutiny, and you want to be sure you document all the important points," Castillo says.

A critical illness or injury acutely impairs one or more vital organ systems "such that the patient's survival is jeopardized," CPT states. CMS regulations further specify that with a critical illness or injury, "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." "In other words, without immediate and high-level physician care, the critically ill or injured patient likely will not live," Castillo says.

When reporting critical care codes, you should state specifically in the documentation what makes the patient's condition critical, says Linda Laghab, CPC, coding department manager for Pediatric Management Group at Children's Hospital, Los Angeles. Vital organ system failure could include, but is not limited to, central nervous system failure, shock and/or respiratory failure.

You may report critical care for a critically ill, injured or postoperative patient only if such care is medically necessary. "Providing medical care to a critically ill patient should not be automatically determined to be a critical care service for the sole reason that the patient is critically ill," CMS regulations specifically state.

For example, a sports accident victim arrives in the emergency department in extreme shock and nervous-system collapse. Following emergency procedures and eight hours of constant care, the patient's condition -although clinically "critical" - stabilizes.

The services the physician provides in the eight hours following the patient's arrival in the ED qualify as critical care because the patient's condition is unstable and life-threatening enough to require high levels of physician intervention. When the patient is stable, and the immediate threat of death or significant function loss is unlikely, you may no longer claim critical care, even though the patient is technically still in "critical" condition, CPT guidelines state.

Although patients often receive critical care in a critical care area (e.g., coronary care unit, intensive care unit, pediatric care unit, emergency care facility), not all care the physician provides in a critical care unit qualifies as critical care as defined by 99291-99292. Likewise, a physician may provide critical care even outside an intensive care unit or other "critical care" area, as long as the patient has a critical illness or injury and the care is medically necessary, CPT says.

For example, the neurologist treats an inpatient in a standard care unit for status epilepticus with psychomotor seizures (345.7x). The patient receives anticonvulsants to stop the seizures and undergoes ventilation and blood pressure and metabolism stabilization. Because the seizures will cause permanent brain damage or even death if not stopped, the neurologist can justify his presence and therefore may report critical care even though she provided the services outside the ICU.

As in the previous example, however, if a patient in an ICU has stabilized so that he or she no longer requires the neurologist's constant attention, you may not report the critical care codes just because the patient is in the ICU.

To claim 99291, the neurologist must document a minimum of 30 minutes spent providing critical care. You may report only one unit of 99291 per claim. Report each additional 30 minutes of critical care beyond the first 74 minutes using add-on code 99292, as follows, Laghab says: