Orthopedic Coding Alert

You Be the Coder:

Critical Care Start Times

Published on Fri Oct 05, 2018

Question: When coding for critical care, is time spent in pre-hospital medical direction as well as coordination of care (activating alerts, setting up rooms/staff, etc.) prior to the patient arriving count in the time toward critical care? Or can the critical care time only begin once the patient arrives?

Montana Subscriber

Answer: You can only code 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)) once the patient arrives, says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

“All CPT^® E/M codes assume pre-work and this is built into the relative value. For instance, 99291 includes 15 minutes of pre-service time according to the AMA’s RBRVS database,” Witt continues.

Also, CPT^® guidelines for critical care state “critical care is the direct delivery by a physician .... of medical care for a critically ill or critically injured patient. Direct care means the physician is present and directly involved in the care,” says Witt.

In addition to CPT^®, Medicare “has been very clear that they only accept critical care time spent with the patient, or on the floor with the patient,” confirms Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “This makes a certain amount of sense because the critically ill patient is one who might need an intervention at any time. If the patient isn’t there, then it is not possible to intervene. Also, it’s impossible to have truly assessed the severity of the patient’s condition if the provider hasn’t seen the patient yet.”

Bottom line: “If the patient is so ill that critical care is appropriate, the physician billing critical care needs to be nearby to intervene immediately. If the patient is not that sick, then critical care is not appropriate,” according to Bucknam.