Oncology & Hematology Coding Alert

A trip to the ICU doesn't always merit 99291-99292 If reporting adult critical care services (99291-99292) leaves you with more questions than answers, here's the help you-ve been searching for.

The five question-and-answer scenarios below should solve all of your most common critical care dilemmas. 1. What Qualifies a Patient for Critical Care? A critical care patient must be -critically ill- or -critically injured,- according to CPT guidelines. A critical illness or injury -acutely impair[s] one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition.-

-In other words, the patient is in immediate, mortal danger without continued, high-level physician involvement,- says Caral Edelberg, CPC, CCS-P, president, chief executive officer and founder of Medical Management Resources of TEAMHealth in Jacksonville, Fla.

Conditions that could call for critical care include (but are not limited to) central nervous system failure, circulatory failure, shock, and renal hepatic, metabolic and/or respiratory failure, according to CPT instructions.

Important: You may use critical care codes for a -stable- patient, but only if the physician's continued focused attention is preventing the patient's condition from deteriorating further.

-If the condition doesn't have the possibility of becoming a truly life-threatening situation, it's probably not critical care,- Edelberg says. 2. Is There a Minimum Time for Critical Care? The physician must spend a minimum of 30 minutes administering critical care services before a visit qualifies as critical care as described by 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), according to CPT. For critical care services lasting fewer than 30 minutes, you will choose an appropriate E/M service code, says Susan Allen, CPC, compliance coder with JSA Healthcare in St. Petersburg, Fla.

Example: The oncologist tends to a patient experiencing cord compression, leading to central nervous system failure. In this case the oncologist is able to stabilize the patient after 25 minutes, after which the patient is no longer in immediate, life-threatening danger.

Because the critical care did not extend to 30 minutes or beyond, you should not report a critical care code. Choose an appropriate E/M code instead.

Example: The oncologist is able to stabilize a patient after 30 minutes, but her condition remains such that she could -go either way.- After another three hours, the patient stabilizes to the point that she is no longer in immediate danger of death.

In this case, you can report 99291 for the first 74 minutes and +99292 (- each additional 30 minutes [list separately in addition to code for primary service]) x 5 for the remaining two hours and 16 minutes. 3. What Activities Count Toward Critical Care Time? You may count toward critical care time spent -engaged in [...]