Neurosurgery Coding Alert

Count the critical care time and check if other services are bundled.

Your neurosurgeon may offer critical care in several situations, not necessarily with a surgical procedure. Unlike other E/M codes, the codes for critical care may leave you confused. Check out these tips on what “critical” actually means and which services are, and are not, bundled into the critical care codes so you can code with confidence.

Insurers May Not Agree Patient Was Critically Ill or Injured

Whether the patient was critically ill or injured is perhaps the most important question you’ll need to answer on any critical care claim. You must be able to establish that the 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]), reports Michael A. Granovsky, MD, FACEP, CPC, President of Logixhealth, a national emergency department coding and billing company based in Bedford, Mass.

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,” Granovsky explains.

“The imminent threat of permanent harm can be to life or organ system, such as the central nervous system, circulatory failure, or respiratory failure,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison.

In addition, minimal time thresholds of care, at least 30 minutes, must be clear from the medical records, says Granovsky. He offers these examples of patients that insurers would consider critically ill or injured: unstable vital signs, severe hypernatremia, which is a high blood sodium level, severe dyspnea, or a hypertensive crisis. Appendix C of the CPT® manual offers various other possible examples, such as a patient with a history of stroke presenting with loss of consciousness. But you must keep in mind that these are examples, and you should always code based on the patient’s specific case and the physician’s judgment of that case. The advice below may help make that decision clearer.

Payers May Question ‘High Probability’

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

When determining whether or not a patient is critically ill or injured, the physician should consider the likelihood that the patient 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 be an appropriate consideration.

Where Can the Physician Provide Critical Care?

Place of service for critical care 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 in any place of service the patient requiring it presents. According to the Medicare database, about 25 percent of all critical care services were provided in the emergency department setting, Granovsky says.

“However, providing critical care services is based on patient condition and the acuity of the service being provided,” Przybylski says. “A patient being monitored in an intensive care unit but whose organ systems are in stable condition may not meet the criteria for critical care services. In contrast, a patient evolving a stroke in your office may initiate critical care services even though the patient has not yet been admitted to the hospital.”

Don’t Forget the Services Bundled into 99291 and +99292

The CPT® critical care preamble includes a specific list of services bundled in to code 99291 that you should not be report 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)
• Peripheral vascular access procedures (36000, 36410, 36415, 36591, 36600).

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

“These are considered bundled services because a typical critical care encounters includes one or more of these procedures,” Przybylski says.

Non-bundles: You can report the below services separately from 99291 and +99292, as CPT® does not bundle them into critical care:

• CPR (92950)
• Endotracheal intubation (31500)
• Tube thoracostomy (32551)
• ECG interpretations (93010, 93042)
• Central venous catheter placement (36555, 36556).

Consider this example: A patient presents with severe headache and stiffening of neck and vomiting. The physician examines the patient for focal neurological deficits. The physician orders labs and CT scan. In addition, the physician does multiple re-evaluations. The physician interprets the CT scan and diagnoses the patient with subarachnoid hemorrhage. The patient becomes obtunded and requires emergency intubation. Endotracheal intubation takes the physician ten minutes, and the rest of the encounter took 46 minutes.

In this example, the physician spent 46 minutes providing critical care services to this patient (this time excludes time spent intubating the patient). On the claim you would report code 99291 for the 46 minutes of critical care and separately reportable CPT® 31500.

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

In the case of code 99291, you’ll find 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, Granovsky explains.

“While the base code 99291 is for a 60 minute service, the threshold to report the code is at least 30 minutes of critical care time,” Przybylski says. “Since the add-on critical care service 99292 is for a 30 minute service (with a 15 minute minimum threshold), the base code 99291 reflects services ranging from 30-74 minutes.”