Neurosurgery Coding Alert

Document the reason for critical care and the services your physician offered.

Critical care coding is integral to neurosurgery coding. The codes for critical care services are different from the E/M codes. The documentation requirements of the two may also differ. You need to clearly understand which service is categorized as 'critical care' and how you can code for the same. Also, you need to know what services are bundled into the critical care codes. 

When Do Insurers Consider A Patient To Be Critically Injured or Ill?

Insurers need a clear clinical indication that the patient meets critical care criteria. Your providers must identify and provide supporting documentation that their patient is critically ill or injured to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (... each additional 30 minutes [List separately in addition to code for primary service]).

CPT® defines critically ill or injured as 'an injury or illness that acutely impairs one or more vital organ systems such that there is high probability of imminent or life threatening deterioration in the patient's condition.'   "This doesn't imply that the patient is at imminent risk of death, significant deterioration and/or imminent failure of an organ system may also justify application of critical care codes," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison.

To make things easy, you must answer yes to these three questions: 

1. Is at least one vital organ system impaired?

2. Is there a high probability of imminent or life-threatening deterioration?

3. Did you intervene to prevent further deterioration of the patient's condition?

In addition, the provider must document that they provided at least 30 minutes of critical care services.

Possible examples of critically ill patients include:

• An acute intracranial bleed that needs consultation and close monitoring;

• Sudden loss of consciousness with unstable vital signs; and

• Projectile vomiting after a road traffic accident with deteriorating mental status.

"If you have not provided at least 30 minutes of care in managing a critical illness, you should report an appropriate level E/M service rather than a critical care service," Przybylski says.

Pay Attention to the "High Probability" Clause

Although most critical patients in the emergency department will be actively critically ill or injured, some may just be unstable to the point that they will very likely become critical without immediate treatment.

When determining whether or not a patient is critically ill or injured, the physician should consider the likelihood that they would have a clinically significant deterioration if nothing was done in the next hour.

If the probability for imminent or life threatening deterioration is high, critical care may still be appropriate to report the service.

"This situation would not be uncommon in traumatic cranial injury in which the early condition of the patient is only mildly impaired but the size/location of the injury is associated with high risk of progression requiring urgent or emergent intervention," Przybylski says.

Where Can the Physician Provide Critical Care?

Place of service is not restricted in CPT® other than to identify typical areas of a facility where it may occur.

While most critical care will occur in a critical care area (ICU, ED, etc.), the physician can provide 99291 services anywhere the patient requires it. In fact, according to the Medicare database, about twenty five percent of all critical care services were provided in the emergency department setting.

Don't Forget the Services That Are Bundled into 99291 and +99292

The CPT® critical care preamble includes a specific list of services that are bundled in to code 99291 and should not be reported separately. These include:

• The interpretation of cardiac output measurements (93561, 93562);

• Pulse oximetry (94760, 94761, 94762);

• Chest x-rays, professional component (71010, 71015, 71020);

• Blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data) (99090);

• Gastric intubation (43752, 43753);

• Transcutaneous pacing (92953);

• Ventilator management (94002-94004, 94660, 94662); and

• Peripheral vascular access procedures (36000, 36410, 36415, 36591, 36600).

Best bet: When your physician provides any of the above services during a critical care session, do not report them separately.

Non-bundled: However, you can report the below services separately from 99291 and +99292, as they are not bundled into critical care:

• CPR (92950);

• Endotracheal intubation (31500);

• Tube thoracostomy (32551);

• EKG interpretations (93010, 93042); and

• Central venous catheter placement (36555, 36556).

"These procedural services are considered separately identifiable procedures which are not accounted for in the typical evaluation and management work provided in critical care services," Przybylski says.

Consider this example: A patient presents with vomiting and intense headache following a road traffic accident. The physician examines the patient and finds him to be tachypneic and tachycardic. Due to continuous difficulty in breathing, an endotracheal intubation was performed. Labs and an EKG are ordered. Multiple re-evaluations are performed prior to intubation and post intubation. The physician interprets the EKG, confirms ET tube placement. The EKG interpretation takes the physician four minutes, intubation 5 minutes and the rest of the encounter took 80 minutes.

In this example, the physician spent 80 minutes providing critical care services to this patient (this time excludes time spent interpreting the EKG). On the claim you would:

• report 99291, 99292 for the 80 minutes of critical care.

• report 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for the EKG.

• report 31500 for the endotracheal intubation.

Watch this: Be sure to deduct the time spent providing these separately billable procedures from your critical care time reported. 

Is It 30 or 31 Minutes to Qualify For Critical Care?

The 2015 CPT® book introduction discusses time threshold requirements for code sets that contain a time basis for code selection, as follows:  "The following standards shall apply to time measurement, unless there are code or code-range-specific instructions in guidelines, parenthetical instructions, or code descriptors to the contrary. A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes). A second hour is attained when a total of 91 minutes have elapsed." 

In the case of code 99291, there is specific language in CPT® that states 30 minutes both in the code descriptor itself and in the time threshold chart in the critical care section preamble. So for 99291, CPT® describes a threshold of at least 30 minutes, when the midpoint would have been passed. 

"Consequently, report CPT® 99291 when a critical care service is provided that lasts between 30 and 74 minutes," Przybylski says. "Additional increments of between 15-30 minutes of critical care service are reported with addition units of 99292."

Use This Time Threshold Calculator

Make sure you have your time thresholds by using this chart from CPT®.

Total Duration of Critical Care Codes:

• less than 30 minutes (less than 30 minutes) appropriate E/M codes

• 30-74 mins. (30 minutes - 1 hr. 14 min.) 99291 X 1

• 75-104 mins. (1 hr. 15 min. - 1 hr. 44 min.) 99291 X 1 AND  99292 X 1

• 105-134 mins. (1 hr. 45 min. - 2 hr. 14 min.) 99291 X 1 AND  99292 X 2

• 135-164 min. (2 hr. 15 min. - 2 hr. 44 min.) 99291X 1 AND   99292 X 3

• 165-194 mins. (2 hr. 45 min. - 3 hr. 14 min.) 99291 X 1 AND  99292 X 4

• 195 mins. or longer (3 hr. 15 min. - etc.) 99291and  99292 as appropriate (see illustrated reporting examples above)

Check with Payers before Submitting Claims with Both E/M and Critical Care

CPT® is clear in stating that critical care and other E/M services may be provided to the same patient on the same date by the same physician. However, Medicare does not agree with that policy.

In its Transmittal 1548, CMS specifically addresses this question with regard to the emergency department. It states that when critical care services are required upon arrival into the emergency department, only critical care codes (99291-99292) may be reported. An emergency department E/M code (99281-99285) may not be reported in addition to those services.

Important: It does not matter if the critical care precedes or follows what would normally be an E/M service in the emergency department. Transmittal 1548 clearly states that hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician (which includes any physician of the same specialty in the same group) to the same patient.

So, if a Medicare patient presents to the emergency department and receives a Level 5 ED E/M workup, and later in the shift unexpectedly clinically deteriorates requiring critical care services, according to CMS, the "same" ED physician would typically report only the critical care service -- but not both.

"When reporting E/M services, it is best to report the most representative and intense service provided," Przybylski says.