Oncology & Hematology Coding Alert

Time to find out if you really are an E/M expert.

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below.

Answer 1: While you may think of critical care as being typically performed in the hospital setting, the reality is that “critical care is not determined by the location in which the care is being delivered,” according to Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia. Or, as CPT^® puts it: “Critical care is usually, but not always [emphasis added], given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility.”

In fact, there are a number of services that a provider can perform even in the office or outpatient setting that can be counted toward critical care when applicable.

This means “the key to applying a critical care code is understanding that the service must be medically necessary and meet the criteria of critical care,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “And providers may report critical care even in a hospital setting if they are specifically the one managing the problem that is critical in nature.”

Answer 2: In order to qualify as a critical care patient, the medical record must demonstrate the patient has an acute impairment of one or more vital organ systems and has a high probability of imminent or life-threatening deterioration.

In addition, in order for you to use 99291/+99292 in the facility setting, your provider’s patient must be older than 71 months. Per the critical care guidelines, report inpatient critical care services provided to neonates (28 days of age or younger) with the neonatal critical care codes 99468 and 99469 (Initial/ subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger), and critical care services provided to infants 29 days through 71 months of age with pediatric critical care codes 99471-99476 (Initial/subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child …). Be sure to review the critical care guidelines for additional information and appropriate reporting of critical care in the outpatient setting.

Answer 3: Even though the critical care code descriptors don’t mention it, CPT^® guidelines require that your provider must demonstrate “high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.”

Answer 4: Arguably, the most important guideline regarding calculating provider time spent administering critical care is that “the individual [provider] must devote his or her full attention to the patient” per CPT^®. This means you can count only time spent, at the immediate bedside or elsewhere on the floor or unit, related to services provided to the critically ill patient toward 99291-+99292.

What counts? You can count time spent “engaged in work directly related to the individual patient’s care,” and on the same date of service “even if the time spent by the individual is not continuous.” Per CPT^® guidelines, activities include:

• “Reviewing test results or imaging studies;
• “Discussing the critically ill patient’s care with other medical staff;
• “Documenting critical care services in the medical record”; or
• “Time spent … 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 … when the patient is unable or lacks capacity to participate in discussions.”

What doesn’t? You cannot count any time where the “individual [provider] is not immediately available to the patient,” including time spent:

• “In activities that occur outside of the unit or off the floor (eg, telephone calls whether taken at home, in the office, or elsewhere in the hospital)”;
• “In activities that do not directly contribute to the treatment of the patient… (eg, participation in administrative meetings or telephone calls to discuss other patients)”;
• “Performing separately reportable procedures or services”; or
• Providing “services to any other patient during the same period of time,” also per CPT^®.

Answer 5: You should code critical care service times below the 30-minute threshold with the appropriate E/M code reflecting the place of service. For instance, if you provided less than 30 minutes of critical care to a patient in your office, you would report the appropriate code from 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …).

Times between 30 and 74 minutes can then be reported with 99291, with times above 75 minutes coded with 99291 and units of +99292 for every additional 30 minutes of service time.

Note the Medicare exception: If you’re billing Medicare for critical care services, you should note that you will only be able to bill +99292 after 104 minutes, as the code is “for additional, complete 30-minute time increments furnished to the same patient (74 + 30 = 104 minutes)” (see, for example, the final rule for CY 2023: www.federalregister.gov/d/2022-23873/ page-69404).

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