Practice Management Alert

If service does not last 30 minutes, use E/M code

When billing for critical care services, focus your attention on the time that staff spend providing services rather than the encounter setting.

Why? A patient does not have to be in a traditional -critical care- setting to receive critical care, says Linda Parks, an independent coding consultant in Marietta, Ga. -The service is based on time spent treating a critically ill or injured patient,- she says. For example, a patient being treated in a hospital's critical care unit is not necessarily receiving critical care services. The patient must meet the definition of critically ill, regardless of the care setting, before you can use 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).
 
Best bet: When putting together a critical care bill, make sure you get an accurate account of the encounter--especially a precise log of how long the encounter lasted, and what services the physician provided.

Patient must be critically ill: Before billing for critical care, the office must be sure the patient meets certain clinical criteria associated with critical illness, said Michael Granovsky, MD, CPC, FACEP, of Medical Reimbursement Systems during the recent Coding Institute teleconference -Critical Care Coding and Reimbursement.- To be certain that the patient meets the definition of critically ill, Parks recommends that billers familiarize themselves with the CPT 2005 definition, which states, -A critical illness or injury 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 is often performed on patients in danger of organ failure, Granovsky said. For example, critical care might be provided for a patient if his claim included notes indicating failure of the central nervous system,  renal failure, metabolic failure, etc.

Physician must provide critical care services: After deciding if a patient is critically ill, the biller must next consider whether the services the physician provided are part of the critical care package. Parks lists the following as services that most carriers will consider bundled into critical care: cardiac output measurements, chest x-rays, pulse oximetry, blood gases and information data stored in computers, gastric intubation, temporary transcutaneous pacing, ventilatory management and vascular access procedures.  

Don't forget these: These services are also often considered part of the critical care package, so do not bill for them separately when billing for critical care,  Granovsky said: bedside patient care; reviewing ancillary studies; discussions with family, rescue, nursing, physicians as related to care and chart documentation and completion

Remember: -Any services performed that are not listed [above] should be reported separately,- Parks says. (For more information on how to report separate services during a critical care encounter, see -If E/M Precedes Critical Care, Bill for It- later in this issue.)

What's not included? The following procedures are typically not considered part of the critical care package, Granovsky said, so consider billing for these services separately on a critical care claim: endotracheal intubation, CPR, triple lumen catheter insertion, transvenous pacer and EKG interpretation.

Also, a solid critical care claim will include documentation describing both the services that the physician provided during the encounter and the exact times that the physician started and stopped critical care. For example, you don't want to submit a claim with documentation merely stating: -Provided 43 minutes of critical care service to a critically ill patient.-

Try this: Submit a claim with documentation stating: -Nov. 2, 43 minutes of cc; patient in danger of cardiac failure. Start, 4:43 a.m., stop 5:26 a.m. Ordered chest x-rays, studied cardiac output measurements, and performed ventilatory management.-

Use 99292 only with 99291: For each half-hour of critical care the physician provides past the first 74 minutes of critical care, report +99292 (... each additional 30 minutes [list separately in addition to code for primary service]), Granovsky said. For example, if your physician provided 143 minutes of critical care, you would bill: 

- 99291 for the first 74 minutes of critical care

- 99292 x 2 for the subsequent 69 minutes of care.

Remember: Code 99292 is an add-on code, meaning you cannot bill for it without 99291. Also, you will not need to include any modifiers when billing 99292 since it is an add-on code, and add-on codes do not require modifiers.