Primary Care Coding Alert

Hint: Patient status and services, not location, drive 99291-+99292 billing.

The adult critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (… each additional 30 minutes …) can present big problems for coders.

First, you must make sure that the patient meets the clinical criteria for the codes. Then, you must make sure you know which services are included in the codes and which are separately reportable. And then there’s the question of how you account for the time your provider spends administering services to a critically ill patient.

These are complex questions that have complex answers. Fortunately, these responses from two coding experts will break everything down for you.

When Can a PCP Bill for 99291-+99292?

While you may think of critical care as being typically performed in the hospital setting, the reality is that “critical care is not determined by the location in which the care is being delivered,” according to Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia. Or, as CPT^® puts it: “Critical care is usually, but not always [emphasis added], given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility.”

In fact, there are a number of services that a primary care physician (PCP) can perform in the office or outpatient setting that can be counted toward critical care when applicable, as we will see later.

This means “the key to applying a critical care code is understanding that the service must be medically necessary and meet the criteria of critical care,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Additionally, “internal medicine providers who are hospitalists and primary care providers in the hospital may report critical care if they are specifically the one managing the problem that is critical in nature,” Falbo adds.

What Clinical Criteria Does a Patient Have to Meet for 99291-+99292?

To simplify this complex question, you should “ask and answer the following questions about the service,” cautions Miller.

1. What is the patient’s condition? In order to qualify as a critical care patient, the medical record must demonstrate the patient has an acute impairment of one or more vital organ systems and has a high probability of imminent or life-threatening deterioration.
2. What is the level of decision making? CPT^® guidelines require that your provider must demonstrate “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.”

In order to justify critical care services, then, your documentation “must be detailed enough to support the critical care visit. On the patient side, this could include statements about the patient’s condition worsening or having a poor prognosis, while on the provider side, this could involve answers to questions such as how a plan of care is being modified and what potential patient outcomes might occur as a result of an existing care plan remaining unchanged,” says Falbo.

What Services Are Bundled Into 99291-+99292?

CPT^® guidelines are also very explicit about which services cannot be reported with critical care services. For 99291-+99292, they include:

• Vascular access procedures (36000, 36410, 36415, 36591, 36600);
• Gastric intubation (43752, 43753);
• Interpretation of chest X-rays (71045, 71046);
• Temporary transcutaneous pacing (92953);
• Interpretation of cardiac output measurements (93561, 93562);
• Ventilatory management (94002-94004, 94660, 94662); and
• Pulse oximetry (94760, 94761, 94762) along with the interpretation of blood gases, and collection and interpretation of physiologic data (e.g. electrocardiograms [ECGs], blood pressures, and hematologic data).

These are all “services that do qualify as critical care when performed in the outpatient or office setting during the critical period by the provider of the critical care,” according to the Journal of Urgent Care Medicine (Source: www.jucm.com/coding-critical-care-services/).

How Do I Count Time When Billing 99291-+99292?

Arguably, the most important guideline regarding calculating provider time spent administering critical care, is that “the individual [provider] must devote his or her full attention to the patient” per CPT^®. This means only time spent related to services provided to the critically ill patient can count toward 99291-+99292.

What counts? Time spent “engaged in work directly related to the individual patient’s care,” including time spent:

• On the same day of service “even if the time spent by the individual is not continuous on that date;
• “Reviewing test results or imaging studies;
• “Discussing the critically ill patient’s care with other medical staff;
• “Documenting critical care services in the medical record”; or

“Time spent … 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 … when the patient is unable or lacks capacity to participate in discussions,” per CPT^®.

What doesn’t? Any time where the “individual [provider] is not immediately available to the patient,” including time spent:

• “Taking telephone calls or in administrative meetings” in locations outside the unit or off the floor where the patient is (e.g. at home, in the office, or elsewhere in the hospital if the patient is in an ICU);
• “In activities that do not directly contribute to the treatment of the patient;
• “Performing separately reportable procedures or services”; or
• Providing “services to any other patient during the same period of time,” also per CPT^®.

Putting it all together: Providing your patient’s status and provider’s services meet all the above criteria, you still may not have enough to report 99291-+99292. That’s because the codes do not kick in until the service time has met or exceeded 30 minutes.

You should code critical service times below that threshold with the appropriate evaluation and management (E/M) code reflecting the place of service. For instance, if you provided less than 30 minutes of critical care to a patient in your office, you would report the appropriate code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). Times between 30 and 74 minutes can then be coded with 99291, with times above 75 minutes coded with units of +99292 for every additional 30 minutes.