Neurosurgery Coding Alert

Many coders get nervous when claiming critical care. CPT devotes extensive explanatory text to the critical care codes (99291 and 99292), and the requirements for reporting can seem daunting. But if you can establish just two points - the potentially life-threatening nature of the patient's condition and that the physician spent at least a half-hour attending exclusively to that patient - critical care coding shouldn't intimidate you.

Point 1: Critical Care = a Serious Threat

If you're coming up short on critical care coding, most likely your documentation is to blame, says Caral Edelberg, CPC, CCS-P, president, chief executive officer and founder of Medical Management Resources, a TeamHealth Company in Jacksonville, Fla. "We see cases that could be critical care yet can't be billed because the documentation just isn't enough to support the selection of the critical care code," she says.
 
As a first step to correctly reporting 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]), you must be able to identify (and document) patients who are "critically ill" or "critically injured," which is the minimum requirement for claiming critical care.
 
A critical illness and injury is one that "acutely impair[s] one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition," according to CPT. CPT further specifies, "Critical care involves high-complexity decision-making to assess, manipulate and support vital system functions, to treat single or multiple vital organ system failures and/or to prevent further life-threatening deterioration." In other words, a critical care situation involves a physician with the highest level of preparedness intervening urgently to stop a patient's condition from becoming worse.
 
A patient's condition may be stable, but if the physician's focused attention is keeping the patient stable, you should be using critical care codes. On the other hand, you cannot use critical care codes simply because the patient resides in a "critical care" unit. "With critical care, you're talking about a situation where the patient could go either way," Edelberg says. "If it doesn't have the possibility of becoming a truly life-threatening situation, it's probably not critical care."
  
For example, an automobile hits a pedestrian on a dark street. The victim suffers multiple traumatic injuries, including head injuries, which require immediate, constant and high-level attention. For four hours following admission, the patient shows signs of intracranial hemorrhage that require a "high level of physician preparedness and intervention," and therefore qualifies as critical care. But when the patient's condition stabilizes such that the immediate threat of death or loss of significant function is unlikely and, specifically, frequent attention and management by the physician are no longer necessary, you may no longer claim critical care.

Point 2: Claim at Least 30 Minutes for Critical Care

Time is the second factor when reporting critical care. The physician must spend a minimum of 30 minutes administering critical care services before you may bill. You may not count separately billable procedures in the time calculation (see below). And, the physician must attend exclusively to that patient during the documented time. Therefore, if the surgeon attends to more than one patient during the same time, he or she could not have administered critical care.
 
In the above example, for instance, you should report the first 60 minutes of care using 99291. You may report the remaining three hours using 99292 x 6. If the surgeon performs any separately reportable procedures at the same time (such as CPR), you should append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the critical care codes.
 
The time the physician spent providing critical care in the above example was continuous, but this is not always the case. "The time requirement is cumulative, not continuous," says Barbara Cole, BSN, RN, CPC, president of ProTech Reimbursement Services, a national firm specializing in emergency medicine professional and technical coding. "You can count time spent engaged in work directly related to the individual patient's care, whether at bedside or elsewhere on the floor or unit."
 
Critical care encompasses actions "in addition to the time spent by the bedside, such as reviewing test results, discussing the case with staff, time spent discussing the situation with the patient's family, making management decisions, and talking to other physicians," Edelberg says. Keep in mind, however, that the clinical activities must directly contribute to the patient's care.
 
When coding, make sure to document clearly and thoroughly all of the time your physician spends providing services. If the physician meets the level-of-service criteria and the time exceeds 30 minutes, you may claim critical care. "Make a note in the record that indicates that the (critical care) time is exclusive of otherwise billable procedures," Edelberg says. "On audit, an auditor from Medicare would look for that note."

Don't Overlook Separately Reportable Procedures

Critical care is not an "all-inclusive" service. Cardio-pulmonary resuscitation, endotracheal intubation, pericardiocentesis, central venous catheter placement, and electrocardiography interpretations are examples of procedures that you may bill separately in addition to critical care. As noted above, to get paid for critical care that occurs on the same day as a separate procedure with a global fee period, you need to append modifier -25 to the critical care code.
 
CPT also lists several procedures as services included in critical care time: cardiac output measurements, chest x-rays, pulse oximetry, reviewing data stored in computers, blood gasses, gastric intubation, temporary transcutaneous pacing, ventilatory management, and certain vascular access procedures. If the physician performs any of these services, you should not report them separately from the critical care.
 
"If it's not listed in the inclusive services in CPT, then you can report it separately," Edelberg says.