Part B Insider (Multispecialty) Coding Alert

Know what constitutes a 'critical illness or injury.'

Question: I've experienced some denials on critical care codes for patients I considered to be seriously ill. Can you review the parameters for coding critical care?

Answer: According to CPT, "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.

Critical care involves 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. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure."

You'll have to prove that the patient met the above criteria before considering 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (... each additional 30 minutes [List separately in addition to code for primary service]). Otherwise, you'll likely receive a denial for your claim.

Tip: Documenting the length of time spent providing critical care is one of the necessary, and often overlooked, requirements to reporting 99291 and +99292. And while critically ill patients require constant physician attention, this does not necessarily mean constant physical contact between the patient and the physician. You may report the time the physician spent working on the critical care patient's case, whether that time was spent at the immediate bedside or elsewhere on the floor, but immediately available to the patient. Thus, time spent reviewing laboratory test results or discussing the critically ill patient's care with other medical staff would count toward critical care time.

Not counted: Time the physician spent in activities that occur outside of the unit or off the floor (for instance, telephone calls, whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care since the physician is not immediately available to the patient. Refer to more details on critical care reporting requirements in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.12 at www.cms.hhs.gov/manuals/Downloads/clm104c12.pdf.