Practice Management Alert

Question: If the physician provides critical care services during the global postoperative period of another procedure, can we bill for the critical care? Or is it included in the global period?


Missouri Subscriber

Answer: Sometimes you are allowed to bill for this critical care. Medical offices may think they should write off all reimbursement for critical care that happens during the global period for a surgery--but there are exceptions.

Example: A patient with non-reducible, right-sided inguinal hernia, CHF, and controlled type II diabetes comes to the hospital for a hernia repair. Three hours after the operation, the patient shows signs of shortness of breath, problems urinating, cyanotic extremities, and an irregular pulse. Soon after the physician arrives at the patient's bedside, the patient goes into cardiac/respiratory arrest, and the physician resuscitates the patient using CPR, IV medications, and intubation/ventilation.

Coding: You should be able to bill for the critical care in this scenario using modifier 24 (Unrelated E/M service by the same physician during a  postoperative period), says Marie West with Medical Data Services in Edmund, Okla. Some carriers may prefer modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for critical care on the same date as a procedure.

Example: In its March/April 2000 bulletin, Cigna Medicare asks you to use modifier 25 for critical care on the same date as a procedure. Medicare no longer bundles services such as endotracheal intubation (31500) or Swan-Ganz catheter insertion (93503) into the critical care codes, Cigna says, so you can bill for same-day critical care using modifier 25.

You should use an ICD-9 code between 800.0 and 959.9 (except 930-939) with critical care codes (99291-99292, Critical care, evaluation and management of the critically ill or critically injured patient ...), says Noridian Administrative Services in its latest provider question-and-answer file. These diagnosis codes will clearly indicate that the critical care was unrelated to the surgery, Noridian says.

-Any serious unexpected adverse effects, even after surgery, that meet the CPT definition of -critical- would work, as long as it had nothing to do with the reason for the surgery,- says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn.

The critical care codes need documentation to support the severity of the illness as well as the complexity of the physician's decision-making, says Jennifer Swindle, senior coding consultant with PivotHealth in Nashville, Tenn. You should document all the time the physician spent in detail.  
 
The answers to the Reader Questions were provided and/or reviewed by Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J.