Neurosurgery Coding Alert

Question: Our surgeon examines a patient with massive cerebral hemorrhage and provides critical care in the ED. How can we bill for the critical care services? Does this qualify for code 99291? This was not in the ICU setting. Can we bill for the services provided in the ED?

Ohio Subscriber

Answer: The massive cerebral haemorrhage qualifies for critical care. According to CPT^® 2016, “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.” The massive cerebral haemorrhage qualifies for critical care.

Codes: You can choose from code 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]) for critical care services.

Timing is key: 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 the services involve stabilizing a critically ill patient — you cannot choose critical care codes. Confirm the duration of critical care in the medical records before you submit codes 99291 or 99292. However, continuity is not important for critical care services. Your physician may provide critical care at staggered intervals. For example: 20 minutes in the morning followed by 30 minutes in the late evening. You can document the total time spent for critical care and maintain documentation for the same.

Less than 30 minutes: 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.

Setting: Critical care typically occurs in a hospital setting. It can be provided in the emergency department, surgical unit, the operating room (OR), critical care unit (CCU), or observation unit.

Diagnosis codes: Consider codes I60.- (Nontraumatic subarachnoid hemorrhage) through I66.-(Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction) for the diagnosis of massive cerebral haemorrhage.

Tip: Documentation is key for all critical care claims. Make sure you have adequately captured the duration and type of critical care your physician provides.