Oncology & Hematology Coding Alert

You can maximize your E/M coding by grasping the "who" and "what" behind critical care. The service has to meet CPT's time parameters, patient condition, and physician action requirements.

So check your encounter notes for the items below.

For coding purposes, a patient must be critically ill or injured for you to report critical care services. "Critically ill or injured patients have one or more vital organ systems acutely impaired, such that there is a high probability of imminent or life threatening deterioration in the patient's condition" if the physician does not intervene, explains Deb Williams, CPC, coding supervisor at Horizon Billing Specialists in Grand Rapids, Mich.

The physician must spend at least 30 minutes providing critical care before you can code for it, however. Note the time requirements in the code descriptors:

99291 -- Critical care, evaluation and management of the critically ill or criticallyinjured patient; first 30-74 minutes

+99292 -- ... each additional 30 minutes (List separately in addition to code for primary service).

Watch out: If your cancer facility or office typicallycalls an advance life support (ALS) ambulance for critically ill patients, watch the clock. If your team responds to an unstable patient but the ambulance arrivesin 10 minutes to take the patient to the hospital, you have not met the 30 minute time requirement for 99291, says Elisa Parra, CPC, HIM supervisor for Alta Bates Summit Comprehensive Cancer Center in Berkeley, Calif.

Some examples of patient conditions that might warrant critical care include the following, according to Williams:

• severe allergic reactions

• sepsis

• impending respiratory failure

• myocardial infarction (MI).

Caution: A patient suffering from one of the listed conditions does not necessarily meet the coding requirements for critical care. The key to critical care patients is the potential for rapid deterioration without immediate physician intervention.

Several services the physician provides to thecritically ill or injured patient count toward critical care time and are not separately reportable. These services commonly include:

• interpretation of cardiac output measurements

• chest X-rays

• pulse oximetry

• blood gasses

• tests that store information digitally (for instance, blood pressures, hematologic data)

• gastric intubation

• temporary transcutaneous pacing

• ventilatory management

• vascular access procedures (not including most of the central line codes).

When totaling critical care minutes, you will need to deduct the time spent performing separately reportable procedures from overall critical care time, including:

• CPR

• endotracheal intubation

• chest tube/central line insertion

• ultrasound interpretation.

You should also deduct teaching time from critical care. Plus, you can't include time spent speaking with people other than the patient if the conversation does not bear directly on the patient's medical care.