Oncology & Hematology Coding Alert

Question: In the afternoon, our oncologist saw a patient for 30 minutes on the hospital floor and provided level-two subsequent hospital care. That evening, she transferred the patient to the intensive care unit. There, the oncologist provided 60 minutes of critical care for the patient. How should I code this? I say there should be more than one code because of the extra time and work provided, but other coders in the office are not so sure. Who's right?


Delaware Subscriber


Answer: You are right. As long as you can prove that the oncologist provided critical care services during a separate second session, you can report the hospital care and critical care separately.

On the claim you should:

report 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: an expanded problem-focused interval history, an expanded problem-focused examination, medical decision-making of moderate complexity) for the subsequent hospital care.

report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care.
 
Heads-up: Before you bill for critical care, make sure you know that critical care includes the care of criticallyill and unstable patients who require constant physician attention, whether the patient is in the course of a medical emergency or not, according to the Medicare Carriers Manual.

Your oncologist should provide decision-making of high complexity to assess, manipulate and support circulatory, respiratory, central nervous, metabolic or other vital system function to prevent or treat single or multiple vital organ system failure.

Typically, physicians administer critical care in a "critical care area," such as the emergency department. But Medicare (and possibly private carriers) will pay for critical care that a doctor provides in any location as long you meet CPT and Medicare guidelines. And remember, just because the patient is in an intensive or critical care unit doesn't mean you can automatically report 99291.

Services for a patient who is not critically ill and unstable - but who happens to be in a critical care, intensive care, or other specialized care unit - are reported using subsequent hospital care codes (99231-99233) or hospital consultation codes (99251-99263).   

And for a physician to bill critical care, she must devote her full attention to the patient, and she cannot render E/M services to any other patient during the same period of time.