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. 
Putting 99291 To Use  
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 [...]