Practice Management Alert

Does the physician's documentation identify a life-threatening condition?

When you receive a denial from a payer for critical care services, you should look back at the physician's documentation to determine whether you should appeal the denial.

The denial may be justified, in which case your office will have to take the loss. But at times, insurers deny legitimate critical care claims.
 
Questions: When a physician provides services that might be considered critical care, billers need to check notes for two crucial items: 
 
- What precisely was the patient's condition that required critical care?

- How much time did the physician spend with the patient?

Once you-ve answered these questions, you can determine whether billing critical care services is appropriate.

Watch for Keywords About Patient Status

Before you bill for critical care services using 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]), make sure the physician documented that the patient's condition warrants critical care.

Required: The physician needs to document that the patient is critically ill, which requires that the patient has at least one organ system that is failing and that the patient's life is in jeopardy.

Know the rule: According to CPT, the patient must have -a critical illness or injury [that] acutely impairs one or more vital organ systems- and requires the physician to perform -decision-making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple organ system failure, or to prevent further deterioration.-

-Intensive- Does Not Equal -Critical-

A patient does not have to be in the intensive care unit (ICU) to be critically ill, and similarly, not every patient in ICU is critically ill, says Pierre Edde, MD, director of the sleep and respiratory services at Uniontown Hospital in Pennsylvania and founder of www.PCSbilling.com.

The key: What matters is the -high probability of imminent or life-threatening deterioration in the patient's condition.-

Time Is a Critical Factor

Critical care time works on a calendar day. The time does not have to be continuous, but you should make sure the physician recorded the time he spent with the patient in the patient's chart and explained everything he did during that time before you bill out critical care services.

Don't Rule Out Other Services

If the physician provides critical care services on the same day that he provides other services, don't automatically rule out billing both. You can bill for another evaluation and management service, such as an initial emergency department or subsequent inpatient visit on the same date you bill for critical care, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Example: The physician sees a patient in the morning and provides subsequent hospital care. Then, in the afternoon, the patient's condition worsens dramatically and the physician provides critical care services. You can bill for both the critical care services and the subsequent hospital care service (99231-99233).
 
Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the subsequent hospital care service to indicate that it was significant and separately identifiable from the critical care service.

You can also bill for services that CPT and the National Correct Coding Initiative (NCCI) don't bundle with critical care services, such as CPR (92950) or the insertion of a Swan-Gantz line for monitoring (93503). But be sure not to include the time the physician spends on these additional procedures in your critical care service time.

Cautionary note: -All of these procedures are considered 000 global days, and it may be necessary, depending on the payer, to indicate that the critical care service was separate and significantly identifiable from the procedures by use of modifier 25 appended to 99291,- Hammer says.