Neurosurgery Coding Alert

Your neurosurgeon provides a medical service to a very sick patient in the hospital that you think might be classified as "critical care." Be sure the service meets all the criteria to avoid miscoding your physician's services.

The descriptors for 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]) include several hurdles you must cross before coding critical care.

Read on to learn how to better understand what "critically ill or injured" and "high complexity" mean; next month we'll dive into other details to keep your coding on the right track.

CPT guidelines state that the patient must be critically ill or injured. This means the illness or injury must acutely impair one or more vital organ systems to the extent that that there is a high probability of imminent or lifethreatening deterioration in the patient's condition.

"In addition to treating the patient's critical instability, the provider must detail the treatment and management of the patient," says Mary Mulholland, MHA, RN, CPC, with University of Pennsylvania Health System in Philadelphia. "The treatment rendered must be reasonable and medically necessary and require the personal management of the critical care physician."

Watch for: Patients who might qualify for critical care can include those presenting with severe hypertension, acute medical status changes, severe headache, confusion, combativeness, restlessness, or sudden/progressive neurological changes on physical examination. Patients with sudden onset of extremity weakness or symptoms consistent with CVA also could fall in that category, Mulholland says.

More examples: Appendix C of CPT includes several examples of high severity cases that might also qualify for critical care service reporting if the patient's condition warrants.

Your physician must use high-complexity medical decision making in assessing and supporting those vital organ systems to prevent the patient from getting worse. CMS states that "critical care"  dentifies a service that "requires the highest level of physician preparedness to intervene urgently" and that "withdrawal of, or failure to intervene, would likely result in clinically significant or life-threatening deterioration."

"Consider a traumatic head injury," says Kenny Engel, CPC, CHC, ACS-EM, CCP-P, compliance officer for Martin Gottlieb and Associates in Jacksonville, Fla. "The physician may have to juggle protection of the airway and ventilation management, plus the monitoring of cerebral blood flow and intracranial pressure, not to mention the myriad of secondary life-threatening conditions that would accompany a severe head trauma."

Example: A patient presents to the emergency department after an auto accident. The patient sustained multiple injuries and required intubation by the EMT in the field. Physical examination by the neurosurgeon indicated the patient was hypotensive and unresponsive on arrival in the ER. His pupils were minimally reactive.

Your neurosurgeon ordered a CT of the head, a chest Xray, ECG, and multiple laboratory studies. IV fluids were adjusted and IV vaso-pressors were initiated to maintain blood pressure. The head CT was consistent with an intracranial hemorrhage; the physician ordered an IV Amicar drip. The neurosurgeon documented 55 minutes of critical care time; you can report 99291.