Oncology & Hematology Coding Alert

As late as 1999, cancer patients admitted to an inpatient facility had to be unstable or at high risk of dying before his or her oncologist could report 99291 (critical care, evaluation and management). Changes in the definitions of critical care services allow oncologists now to bill for the complex care and medical decision-making that are needed in caring for patients whose disease or treatment has impaired vital organ systems and may be life-threatening.
 
In the past, oncologists were inclined to report 99223 (initial hospital care), the highest level of E/M for an inpatient encounter, when a patient's condition had deteriorated significantly but not enough to be immediately life-threatening.
    
"Physicians frequently undercode in this area," says Dianna Hoffbeck, president of Northshore Medical in Atlantic City, N.J.
   
Defining Critical Care

    
Oncologists also fail to use critical care service codes because many don't realize that the definition of critical care has changed in the past few years, says Nancy Giacomozzi, office manager for P.K. Administrative Services in Lakewood, Colo.
    
"It's been redefined," she says. "It no longer means that the patient faces imminent death. Now, the patient can have a critical condition leading to other life-threatening situations, such as heart or kidney failure. However, there are a lot of old-school billers who would not use (99291) because they still think death has to be imminent."
 
Medicare regulations set forth the following characteristics for critical care:
 

Direct delivery of medical care by a physician to a critically ill or injured patient.
 

The critical illness or injury acutely impairs one or more vital organ systems so there is a high probability of imminent or life-threatening deterioration in the patient's condition.
 

The physician must exercise highly complex medical decision-making to assess, manipulate and support vital systems function. Care may be used to treat system failure or to prevent further deterioration of the patient's condition.
 

Typically requires interpretation of multiple physiologic parameters and/or application of advanced technology.
 

Although the above are typical of critical care services, they do not necessarily have to be present during life-threatening situations.
 

Care is typically provided in the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit or emergency department, but is not specifically limited to these sites.
 
Examples of vital organ systems include the central nervous, circulatory and respiratory systems. Because these systems must be maintained and deterioration of them may lead to other life-threatening conditions, treating their decline should be considered safe harbors for using 99291, Hoffbeck says. 

 
To bill for critical care, the physician must devote his or her full attention to the patient and, therefore, cannot render E/M services to any other patient during the same period of time.
 
Critical care services are reported based on the duration of the visit, unlike normal E/M service, which is primarily based on the exam, history and medical decision-making. If the duration of the critical service is less than 30 minutes, the physician may not report 99291. Instead, the appropriate inpatient E/M code, such as 99223, should be used. Code 99291 is reported once for the first 30 to 74 minutes. Add-on code +99292 should be reported for each additional 30 minutes spent beyond the first hour and 14 minutes.
 
The duration of critical care that should be reported  includes the time the physician spent working on the patient's case. That time may be spent at the immediate bedside or elsewhere on the floor, as long as the doctor is immediately available to the patient.
 
For example, time spent reviewing laboratory test results or discussing the patient's care with other medical staff in the unit or at the nursing station on the floor would be reported as critical care, even if it does not occur at the bedside.
 
Time spent in activities that occur outside of the unit or off the floor, such as telephone calls -- whether taken at home, in the office or elsewhere in the hospital -- may not be reported as critical care. Counseling, either with the patient or family, is not considered critical care. However, if the patient is unable to talk to physicians or is clinically incompetent to participate in a discussion, the time spent with the family to obtain medical history, to review patient condition or prognosis and to discuss treatment can be included in the total time spent providing critical care.
 
Time spent in activities that do not directly contribute to the treatment of the patient may not be reported as critical care even if they are performed in the critical care unit at a patient's bedside. Such activities include telephone calls to discuss other patients, or reviews of  professional literature.
 
Consider a patient diagnosed with breast cancer (174-174.9). Code 99291 can be used appropriately if the disease required the oncologist to admit the patient to an inpatient facility and he or she has an irregular or weak heartbeat.
 
ICD-9 code 174-174.9 should not be used as the primary diagnosis for 99291. Instead, 428.9 (heart failure, unspecified) should be listed as the primary diagnosis, and the breast cancer diagnosis code should be listed second, Giacomozzi says.

Bundling Services

 
Although 99291 provides more reimbursement than other E/M services, many procedures that are performed as a result of critical care should be bundled to 99291.    

According to Medicare policy, many procedures, such as venipuncture, 36410; routine venipuncture, G0001; and ventilation, 94656, 94657, 94660 and 94662, are not paid when they are provided on the same day by the same physician providing the critical care. For a complete list of procedures that are bundled with critical care codes, consult your local medical review policies.