Ophthalmology and Optometry Coding Alert

Your ophthalmologist documents that a patient suffered "critical" eye injuries and underwent major surgery. You should report a critical care code along with the procedure code because the patient was critically ill, correct? Wrong.

You must meet all three of the following key criteria to report critical care services:

• The patient must meet the definition of critically ill or critically injured. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition.

• The physician must perform critical care services. Critical care requires high-complexity decision-making to assess, manipulate and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient's condition.

• Critical care services require a cumulative time of at least 30 minutes on a given date of service. Time can be continuous or intermittent on the date of service and must be clearly documented in the medical record.

Ophthalmologists rarely perform qualified critical care services, and if you report critical care codes inappropriately, the denials will pile up. Make sure you're confident when "critical" cases cross your desk by following these expert tips.

Before you use 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]), you should review how CPT defines a critical care patient.

According to CPT, the patient must have "a critical illness or injury [that] acutely impairs one or more vital organ systems" and requires the ophthalmologist to perform "decision-making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple organ system failure, or to prevent further deterioration."

If your ophthalmologist's services do not meet the criteria for critical care services, you should not report 99291 or 99292. "If all criteria are not met to report a critical care code, the physician would report the appropriate E/M visit and service level documented in the medical record" (such as subsequent hospital care, 99231-99233; or inpatient consultations, 99251-99255), says Cindy Parman, CPC, CPC-H, RCC, co-founder of Coding Strategies Inc. in Powder Springs, Ga.

Just because your ophthalmologist provides care to a critically ill patient, you shouldn't automatically assume you can code his services using critical care codes.

Example: An ophthalmologist performs surgery, and the patient has complications that result in the physician admitting the patient to the intensive care unit (ICU). When the ophthalmologist later performs rounds and visits the patient in the ICU, you shouldn't assume this is critical care because he may not be providing critical care services to the patient (the patient care may only be related to the post-op care for the ophthalmic surgery and not necessarily the patient's critical illness) or meet the time requirements for critical care.

Note: A patient does not have to be in an ICU to be critically ill, and similarly, not every patient in ICU is critically ill, Parman says.

Be clear: The word "stable" is often confusing for physicians and coders alike, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "The patient may be 'stable' due to the interventions provided. Remove the intervention, and the patient may severely decline."

The critical care codes are time-based, so you need to look at your ophthalmologist's documentation to determine which code you should report. For the first 30 to 74 minutes of critical care your physician provides, report 99291.

For each additional 30 minutes, you'll add 99292. If the physician spends less than 30 minutes providing critical care to the patient, you have to choose another appropriate E/M code.

Remember: Time that your ophthalmologist spends performing separately reportable procedures does not count as critical care. And the physician's critical care time should not overlap with critical care time reported by anyone else on the same day.

"If multiple physicians from the same practice participate in the same critical care service, only one physician may report the critical care time. Generally, this is the physician responsible for orders and patient care," Parman says.