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Oncology & Hematology Coding Alert

Reader Question:

99291 Pays More Than 99215

Published on Sun Feb 01, 2004

Question: Are there any advantages to choosing critical care codes rather than high-paying E/M codes?

New Hampshire Subscriber

Answer: Even though you should first choose the appropriate E/M code based on proper coding and documentation, an advantage to using critical care codes (99291-99292) is that you may find that your local carrier pays more for those codes than for high-level E/M codes (for example, 99205 and 99215).
 
For instance, HGSAdministrators (HGSA) in Pennsylvania pays about $256 for 99291. On the other hand, if you submitted level-five new patient code 99205 to HGSA, you could expect about $180, a difference of $76. But to improve your reimbursement, you must medically justify using 99291-99292, or your insurer may deny your claim.
 
Often oncology coders resist using critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]), because they believe the codes are meant for hospitals.
 
You may use these higher-paying codes in the office if you follow CPT's guidelines for reporting critical care services. For three key points of CPT's definition of critical care, review the following:

 

  •  CPT defines a critical illness or injury as one that impairs one or more vital organ systems. This creates a high probability of imminent or life-threatening deterioration in the patient's condition.
     
  •  In critical care, the physician treats single or multiple vital organ system failure(s) and/or prevents further life-threatening deterioration of the patient's condition. The physician must continue these life-sustaining services for 30 minutes to qualify for 99291.
     
  •  Although the physician does not usually provide these services in the office for an extended time, he or she may perform them until the patient can be transported to a hospital or critical care unit.

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