Neurosurgery Coding Alert

Duration of care for critical illness or injury is important for 99291/99292.

Critical care is a key component in neurosurgical procedures. One of the most difficult decisions to make is when you are coding evaluation and management (E/M) services in critical care. There are two codes that you should target and carefully choose from:

• 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]).

Beware:

You need to be firm about critical care services before you can code them. Else, you invite audits for your practice. However, if you neglect 99291/99292 when you could have used them, you’ll be costing the practice deserved reimbursement.

Here are the top 5 questions that you may have as you try to build a greater understanding of 99291/99291 coding. Answers from experts provide guidance for correct coding and stronger claims.

Q: What does “critically ill or injured” mean?

A: CPT^® states that a patient must be critically ill or injured in order to use critical care codes so you’ll need to be sure you know what that means before tackling a critical care claim.

CPT^® 2016 “states that a critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition” if the patient does not receive immediate care, explains Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Mich.

Some patients that your provider might provide critical care services include those who suffer:

Acute brain injury (S06.-, Intracranial injury)

Massive cerebral hemorrhage (I60.-, Nontraumatic subarachnoid hemorrhage through I66.-, Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction)

Status epilepticus (G40.-, Epilepsy and recurrent seizures, often with a sixth character of 1)

Respiratory failure in Guillain-Barre’ Syndrome (J96.0-, Acute respiratory failure, as well as G65.0, Sequelae of Guillain-Barre syndrome [for the sequelae of Guillain-Barre syndrome]).

Q: A patient’s critically ill. The physician prevents further deterio­ration. That’s critical care, right?

A: Definitely consider this for critical care. The clock matters when considering 99291/99292.

As the code descriptor states, the provider must perform at least 30 minutes of critical care before you can consider 99291. When the physician provides less than 30 minutes of care — even if she’s stabilizing a critically ill patient — you cannot choose critical care codes.

Recourse: If the total time spent providing critical care services doesn’t last at least 30 minutes, leave 99291 alone and choose the appropriate evaluation and management (E/M) code based on the encounter notes. For example, if the care occurred in the emergency department (ED), you might be able to choose 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity…) — if the encounter notes justify this high-level E/M code.

“One cannot report critical care code 99291, even if critical care services were provided, when the minimum time threshold of 30 minutes is not met,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.  “However, CPT^® 99291 describes critical care services generally provided for one hour.  Similarly, one may not report CPT^® 99292 for the next 30 minutes of critical care until the minimum threshold of 15 minutes is met beyond the first hour included in CPT^® 99291.”

Q: Does documentation matter on critical care claims?

A: Yes, absolutely. In fact, the critical care provider must document that he/she performed critical care in the encounter notes you’ll file with the claim.

A simple note such as “provided 33 minutes of critical care for patient X” would suffice, but make sure you have that documentation on the claim. Without documentation from the physician that specifies exactly how much critical care time she provided, your 99291/99292 claims won’t fly.

“The documentation should include not only the time spent, but also documentation of the critical illness that you are treating along with the critical care services provided,” Przybylski says.

Q: In which settings can a physician perform critical care?

A: Critical care can occur in any setting, says Sharon Richardson, RN, compliance officer for E/M services at Emergency Groups’ Office in San Dimas, Calif. The ED or intensive care unit (ICU) might see the lion’s share of critical care encounters, but they can occur anywhere.

Nuts and bolts: “If the patient is critical and the physician provides 30 or more minutes of critical care services, they can bill for critical care,” explains Richardson.

Still, Richardson says most critical care occurs in a hospital setting, and it could be in any area including:

• Med-surg unit
• Operating room (OR)
• Radiology unit
• Critical care unit (CCU) or
• Observation unit.

“There is no clinical location or specific site requirement to report critical care codes.  It is the nature and duration of the service that is key to reporting critical care,” Przybylski says.

Critical care in an office setting is possible, but not likely. Usually, if a patient is critically ill in the office, the provider will call 911 while caring for the patient. These are instances in which the physician might provide “critical care,” but doesn’t reach the 30-minute threshold.

Exception: “If the physician follows the patient to the hospital and continues treatment, the combined times could support critical care,” Richardson says.

Q: Does critical care need to be continuous?

A: No. The physician could, for example, provide 35 minutes of critical care in the morning, then 23 more in the afternoon, confirms Richardson.

Caveat: You’ll need to be absolutely sure that the physician provided critical care for the entire time you are coding for — and that the physician documented this fact in the medical record.  

“Otherwise, you may need to report other applicable E&M services if the summation of time spent in providing critical care among multiple encounters does not meet the 30 minute minimum threshold,” Przybylski says.