Part B Insider (Multispecialty) Coding Alert

Beware: CPT, CMS differ on 'family discussion' parameters.

When the physician treats a patient with a critical illness or injury, coders need to know when to start and stop the critical care clock in order to avoid miscoding. Check out these two FAQs to find out what's part of critical care, what's not, and how to correctly count the minutes to ensure the most accurate and profitable 99291-+99292 claims.

Be careful when considering critical care minutes; many services that you might think are part of the 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) package are actually separately billable procedures, pointed out Caral Edelberg, CPC, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La., during her recent presentation on ED trauma coding at The Coding Institute's multi-specialty conference in Orlando, Fla. (www.codinginstitute.com).

"The critical care clock stops,"explains Edelberg, during separately billable procedures such as CPR; endotracheal intubation; chest tube/central line insertion; ultrasound interpretation; and laceration/orthopedic repairs.

Critical care time also excludes the following:

• teaching time aside from the actual care

• most time spent speaking with authorities, family members, or caregivers that do not directly bear on the patient's medical care. (There are exceptions to this rule; check FAQ 2 for more info.)

Also, don't just use total time the patient spends in the ED, because not all of it is active critical care time.

Example: The physician provides uninterrupted treatment of a critically ill patient for a total of 84 minutes. During that time, he performs CPR for eight minutes, spends three minutes teaching, and discusses the patient's condition with family members for five minutes. In this instance, the physician provided 68 minutes of critical care (84 - 8 - 3 - 5 = 68), which you'd report with 99291.

Most other services that the physician provides to the critically ill patient are part of the 99291 package, including interpretation of cardiac output measurements, chest x-rays, pulse oximetry, blood gasses, and information data stored in computers (such as ECGs, blood pressures, and hematologic data); gastric intubation; temporary transcutaneous pacing; ventilator management; and vascular access procedures (though not most central line codes).

'Discussion' exception: Though most interactions with authorities, family members, or caregivers are typically not part of critical care time, there are exceptions, points out Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

"[Critical care] time does not include time speaking with family/authorities -- unless obtaining history or discussing advanced directive matters," Edelberg noted. CPT and Medicare have specific commentary regarding what types of circumstances and conversations outside of direct patient care may count toward critical care time:

Medicare rules: The interactions are part of critical care when "the patient is unable or incompetent to participate in giving a history or making treatment decisions, and the discussion is necessary for determining treatment decisions," Contreras says.

CPT rules: CPT states that when the patient is unable or clinically incompetent to participate in discussions, you may report time spent on the floor or in the unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient's condition or prognosis, or discussing treatment or limitation(s) of treatment as critical care, provided that the conversation bears directly on the medical decision making.