Neurosurgery Coding Alert

When you see certain phrases in your neurosurgeon's notes, chances are you could be billing for critical care rather than settling for the lower reimbursement of standard E/M codes.

"We do so much more critical care than what we bill for. It's unbelievable," Caral Edelberg, CPC, CCS-P, CHC, told attendees at the recent American Academy of Professional Coders conference in Seattle. To collect critical care dollars -- and stay compliant -- physicians and coders must work closely together, says Edelberg, president and CEO of Medical Management Resources in Jacksonville, Fla.

Red flag that you-re missing critical care cash: Go back to the records and trace your patients who were later admitted to the intensive care unit (ICU), Edelberg says. If the bulk of those ICU admissions weren't billed as 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]), you-ve missed the chance to collect those dollars.

"Typically, most ED patients requiring admission to the ICU have had critical care in the ED," Edelberg says.

The catch: Even if your neurosurgeon provides critical care services to a patient in the ICU, there is a chance that you won't be able to code 99291 or 99292. To use these codes, the neurosurgeon must perform a minimum of 30 minutes of critical care.

Otherwise, you may have to code the service with an emergency department E/M code, such as 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity).

"I can guarantee you that many critical care cases are not coded properly because of incorrect documentation," Edelberg adds. So coders should educate physicians to provide better documentation about time and content so we can submit those critical care claims.

To meet the CPT critical care coding criteria, there must be "a high probability of imminent or life-threatening deterioration in the patient's condition involving one or more organ system(s)."

Critical care does not require unstable vital signs, Edelberg says. But critical care does "involve high-complexity decision-making to assess, manipulate and support vital system function" as well as "to prevent further life-threatening deterioration of the patient's condition," Edelberg says.

Example: The ED admits a man in a coma with severe hypertension. A head CT reveals a thalamic hemorrhage with some intraventricular extension and mild hydrocephalus. The ED physician calls the neurosurgeon to evaluate the patient.

The neurosurgeon initiates intravenous medications to control the blood pressure and has the patient intubated to manage the airway and provide mild hyperventilation. The neurosurgeon orders intravenous mannitol and proceeds with placement of a twist-drill ventriculostomy for intracranial pressure monitoring and CSF drainage.

The neurosurgeon spends 102 minutes with the patient for the medical management of the blood pressure and elevated intracranial pressure (but excluding the ventriculostomy placement) before stabilizing him and admitting him to the ICU.

On the claim, you should report the following:

- 99291 for the first 74 minutes of critical care

- 99292 for the rest of the critical care minutes

- 331.4 (Obstructive hydrocephalus) and 431 (Intra-cerebral hemorrhage) linked to 99291 and 99292 to prove medical necessity for the critical care

- 61107 for the ventriculostomy

- 331.4 and 431 linked to 61107 to prove medical necessity for the ventriculostomy.

If you see these conditions in your physician's note, chances are that he provided critical care, and you need to educate your doctors to provide the documentation necessary to submit a critical care claim:

- Intracerebral hemorrhage with impaired consciousness

- Spinal cord injury

- Cervical dislocation

- Subarachnoid hemorrhage with impaired consciousness

- Cardiac arrest

- Comatose/unconscious, unknown cause at

presentation

- Dehydration with significant metabolic blood chemistry changes

- Glasgow Coma Scale below 14

- Head injury, severe, unresponsive

- Hypoxia/hypoxemia

- Unstable vital signs

- Hypernatremia

- Open fracture

- Significant pulmonary emboli

- Rapid heart rate requiring IV therapies and/or close monitoring in ED

- Seizure, new onset or with disorder history, postictal with intensive drug management

- Sepsis/septicemia

- Severe bleeding, requiring transfusion

- Shock-unresponsive patient

- Status epilepticus

- Stroke

- Trauma, multiple, altered consciousness, life or limb threatened.

Even as you alert your neurosurgeons to opportunities to bill for critical care, you must educate them about time documentation requirements, how time is aggregated, and what critical care does not include.

Critical care does not include time spent on separately billable procedures, such as endotracheal intubation and laceration repair, for example. "And some doctors will overestimate time," Edelberg says.

She tells the story of one well-meaning doctor who documented eight hours of critical care. She said to him, "We have to talk about this because you had 40 other patients whom you took care of during those eight hours." The doctor replied, "You told me critical care was all about how much time I spent thinking about a patient's condition, and I was worrying about him the whole time."

Consider giving physicians a template that helps them record critical care time, Edelberg says. This strategy tackles the time overestimation problem and helps them remember to document things like time spent interpreting tests, time thinking about treatment options, and time with the patient's family.