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.

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."

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 further advised carriers, "Claims for critical care services should be denied if the services are not reasonable and medically necessary. If the services are reasonable and medically necessary but they do not meet the criteria, then the services should be recoded as another appropriate E/M service (e.g., hospital visit)."

In addition, although critical care is usually (but not necessarily) provided in a critical care area (e.g., coronary care unit, intensive care unit, pediatric care unit, emergency care facility), the fact that a patient is housed in a critical care unit does not mean that all services provided to that patient qualify as critical care. For example, a traffic-accident victim with multiple traumatic injuries, including head injuries, requires urgent attention. After emergency surgery and eight hours of constant care, the patient's condition although clinically "critical" stabilizes. During this period, the patient could "go either way." The services provided in the eight hours following surgery qualify as critical care because the patient's condition is unstable and life-threatening enough to require a high level of physician preparedness and intervention. When the patient's condition has stabilized to the point that the immediate threat of death or loss of significant function is unlikely and, specifically, frequent attention and management by the physician is no longer necessary in this example, after the first eight hours following surgery critical care may not be claimed.

To report critical care, CMS requires, "the physician must devote his or her full attention to the [critically ill or injured] patient and, therefore, cannot provide services to any other patient during the same time period."

For instance, returning to the example of the trauma patient, if the surgeon claims eight hours of critical care (e.g., from 11 a.m. to 7 p.m.) and a second trauma patient arrives during that time, the surgeon cannot treat the second patient and still claim critical care for the first. By definition, if the physician is not immediately (and necessarily) available to the first patient, critical care has not been provided.

Critical care codes are time-based and include only specific services. Therefore, physicians reporting 99291-99292 must provide thorough and accurate documentation outlining the services provided and the amount of time spent providing them.

To claim 99291 the physician must document a minimum of 30 minutes. If fewer than 30 minutes of critical care are provided, the service should be reported using another appropriate E/M service code (e.g., 9921x, Office or other outpatient visit for the evaluation and management of an established patient ). Only one unit of 99291 should be reported per claim. Each additional 30 minutes of critical care beyond the first 74 minutes is reported using add-on code 99292, as follows, advises Linda Laghab, CPC, coding department manager for Pediatric Management Group at Children's Hospital, Los Angeles: