Neurosurgery Coding Alert

Many neurosurgeons provide critical care but don't report the services as such because the billing requirements for 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]) appear too confusing or extensive. But critical care codes although perhaps less familiar are no more difficult to report than other E/M service codes. Understanding the definition of "critical care" and providing careful documentation are all that is necessary to bill 99291 and 99292 successfully. Defining "Critical Care" The CPT definition of critical care has undergone several revisions. According to the latest guidelines unveiled in CPT 2001, "Critical care is the direct delivery by a physician of medical care for a critically ill or critically injured patient." CPT goes on to specify, "A critical illness or injury acutely impairs one or more vital organ systems such that the patient's survival is jeopardized. The care of such patients involves decision making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple organ system failure, or to prevent further deterioration."

Following publication of the new definition for critical care, CMS released a memo to its carriers to clarify when 99291 and 99292 were appropriate. Noting that the term "unstable" had been removed as a requirement to describe a critically ill or injured patient, the memo explained that the following criteria must be met:

1. Regarding the patient's clinical condition, the memo states, "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."

2. Regarding treatment, the memo specifies, "Critical care services require direct personal management by the physician. They are life- and organ-supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis likely would result in sudden, clinically significant or life-threatening deterioration in the patient's condition." Limits of Critical Care Care for a critically ill, injured or postoperative patient can be defined as critical care only if both the injury or illness and treatment meet the above requirements. CMS has specifically instructed its carriers, "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. The service must be medically necessary and meet the definition of critical care services as described previously to be covered." CMS has [...]