Neurosurgery Coding Alert

According to CPT, critical care codes 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]) may be reported in addition to other billable services with proper documentation under certain circumstances. CPT, however, specifically includes some procedures as bundled to critical care. The following are included in reporting critical care when performed during the critical period by the physicians providing the care. Chest x-rays (71010, 71015, 71020) Blood gases (82273) Interpretation of cardiac output measurements (93561, 93562) Information data stored in computers (e.g., electrocardiographs [EKG], blood pressures, hematologic data [99090]) Gastric intubation (43752, 91105) Pulse oximetry (94760, 94761 and 94762) Transcutaneous pacing (92953) Ventilator management (94656, 94657, 94660 and 94662) Vascular access procedures (36000, 36410 36415, 36540 and 36600) "Any services performed which are not listed above should be reported separately," CPT concludes. Typically, these might include 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes) and 31500 (Intubation, endotracheal, emergency procedure). When you report 99291/99292 with other procedures, however, some payers (e.g., Medicare) may require that modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) be appended to the critical care codes to indicate that the service was "above and beyond the usual pre- and postoperative care." And, critical care codes may be reported on the same day as other E/M services, advises Linda Laghab, CPC, coding department manager for Pediatric Management Group at Children's Hospital, Los Angeles even though CPT rules usually prohibit billing more than one E/M code per encounter if the patient's condition, as well as the physician's documentation, supports combined use of the codes. Once again, modifier -25 is required. For example, the surgeon may provide subsequent hospital care (99231-99233) for a trauma patient in the morning. Later in the day, the patient's condition may worsen, requiring that the surgeon provide an hour of critical care. In this case, report 9923x and 99291-25.

Laghab says the surgeon should separate the critical care documentation from any other E/M documentation provided on the same date of service. The surgeon should dictate a critical care note describing the patient's condition and the treatment to justify 99291 and/or 99292. According to the Medicare Carriers Manual, section 4822.A.9, critical care may be reported during a surgical global period if "the critical care is above and beyond and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed." If critical care is provided postoperatively within the global period, modifier -24 (Unrelated evaluation and management service by [...]