Neurosurgery Coding Alert

Don’t separately report the services that are bundled into critical care.

If your neurosurgeon uses high-complexity decision-making to assess, manipulate, and support vital system functions to treat a patient who suffers from vital organ system failure or to prevent further life-threatening conditions, you may be able to report the critical care E/M codes — 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 should be careful when reporting the critical care codes because CPT^® gives you very specific guidelines for these codes. Shatter the following myths to make sure you always report critical care appropriately in your practice.

Myth 1: Critical Care Doesn’t Have to Meet Certain Requirements

Reality: To qualify for critical care, the service must meet specific requirements, according to CPT^®.

These requirements are as follows:

• The patient must have a critical illness or injury that “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,” according to CPT®. “The imminent threat of permanent harm can be to life or organ system, such as the central nervous system, circulatory failure, or respiratory failure,” explains Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.
• The physician must perform the critical care services, including using high-complexity decision making to assess, manipulate, and support vital system functions to treat vital organ system failure or to prevent further life-threatening conditions.
• All critical care services must last at least 30 minutes on a given date of service. The time can be continuous or intermittent.

There must be documentation of a critical illness or injury that acutely impairs one or more vital organ systems leading to imminent or life-threatening deterioration in the patient’s condition, explains Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, president and CEO of SLG, Inc. Consulting in Raleigh, North Carolina. However, just because a patient is critically ill or injured or in the ICU, doesn’t mean the care should automatically be a critical care service.

“Critical care services can be provided anywhere, in an ED, a Med/Surg room, a clinic, PACU, or even the hospital parking lot, but there must be clear evidence of medical necessity and intensity of care beyond the standard E/M codes, and the physician must be immediately available to the patient,” Goodman says. “Thus, documentation of the patient’s condition, complexity of medical decision-making, interventions performed, and time spent providing critical care services are vital to correct coding.”

Take a look at some examples of patient conditions your surgeon might be able to provide critical care services for, provided the E/M service meets all of the criteria mentioned above:

• S06.- (Intracranial injury) for an acute brain injury
• I60.- (Nontraumatic subarachnoid hemorrhage)-I66.-(Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction) for massive cerebral hemorrhage
• G40.- (Epilepsy and recurrent seizures) for status epilepticus
• J96.0- (Acute respiratory failure) for respiratory failure in Guillain-Barre’ Syndrome.

Myth 2: No Service Bundled Into Critical Care

Reality: The CPT^® guidelines include a specific list of services bundled into code 99291 that you should not be report separately. These services are as follows:

• The interpretation of cardiac output measurements (93561, 93562)
• Pulse oximetry, blood gases, and collection and interpretation of physiologic data (eg, ECGs, blood pressures, hematologic data) (94760-94761, 94762)
• Chest x-rays, professional component (71045, 71046)
• Gastric intubation (43752-43753)
• Temporary transcutaneous pacing (92953)
• Ventilator management (94002-94004, 94660, 94662)
• Vascular access procedures (36000, 36410, 36415, 36591, 36600).

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

Don’t miss: When your physician provides any of the above services during a critical care session, you should not report them separately. However, facilities can report these services separately.

Myth 3: Time Isn’t Important Factor for Critical Care

Reality: Time is a vital component of the critical care codes. The physician should always record the time he spent with the patient in the medical documentation.

“The documentation must include the total time the physician spent in critical care for/with the patient,” emphasizes Suzan Hauptman, MPM, CPC, CEMC, CEDC,  director compliance audit at Cancer Treatment Centers of America “It does not have to be continuous, but it does have to be the total time on one full calendar day. Without this, the coding team would never know how long Dr. X spent with the patient.”

You should report 99291 for the first 30-74 minutes of critical care on a given date. You should report 99291 only once per date even if the time the physician spends is not continuous on that date. You should report critical care of less than 30 minutes total duration on a given date with the appropriate E/M code, not a critical care code.

Then, you should report +99292 for additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes.

“The time that can be reported as critical care is the time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit,” according to the CPT^® guidelines.

You can report critical care: The physician can report the time he spends on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff, or documenting critical care services in the medical record as critical care, even though these services did not occur at the patient’s bedside.

Also, “when the patient is unable or lacks capacity to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient,” per the guidelines.

Don’t report critical care: However, any time the physician spends in activities outside of the unit or floor, such as telephone calls he takes at home, in his office, or somewhere else in the hospital, would not count as critical care because the physician is not immediately available to the patient in these circumstances.

Additionally, if the physician spends time in activities that do not directly contribute to the patient’s treatment, such as administrative meetings, he cannot report these services as critical care, even if he performs these activities in the critical care unit, according to the guidelines.