Primary Care Coding Alert

Medicare release clears up family counseling, concurrent care rules

If you can spot critical care indicators, and your FPs are diligent about documenting encounter specifics, you can capture critical care each time the physician provides it.

To help coders with this process, CMS released transmittal 1530 on June 6 (http://www.cms.hhs.gov/Transmittals/downloads/R1530CP.pdf). This document puts all critical care coding guidance in one easy-to-access place, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

The transmittal, effective July 1, makes especially clear points on documenting family counseling time and coding for concurrent critical care. Keep it handy when you-re coding for 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]).

Use CMS List of Approved -Counseling- Activities

The transmittal spells out exactly what interactions with the patient's family you can count toward overall critical care time, confirms Pohlig.

According to the transmittal, "CPT codes 99291 and 99292 include pre- and post-service work. Routine daily updates or reports to family members and/or surrogates are considered part of this (included) service." So if the FP meets for three minutes with a patient's wife to give her an update, you should not count this as critical care time.

Exception: When the critically ill or injured patient is unable or incompetent to give a medical history or make treatment decisions and a discussion to determine treatment decisions is necessary, you can count time spent consulting with the family toward critical care.

You-ll need to be sure to document the family counseling time properly, Pohlig warns. When recording family counseling time for critical care, the transmittal states that the provider must document:

- that "the patient is unable or incompetent to participate in giving history and/or making treatment decisions;

- the necessity to have the discussion (e.g., -no other source was available to obtain a history- or -because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family-);

- medically necessary treatment decisions for which the discussion was needed; and

- a summary in the medical record that supports the medical necessity of the discussion."

Show Physicians the Value of Documentation

Your FPs also need to be diligent about documenting the other critical care components. Often, physicians do not provide enough information on encounter forms to justify critical care coding.

"Critical care is commonly performed but underreported. I believe many (physicians) often miss critical care coding opportunities," said Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla.

Bottom line: To report 99291, the physician needs to spend a minimum of 30 minutes providing critical care to the critically ill or critically injured patient. If the physician performs activities that count toward that time, but does not include them in the documented time, then appropriately coding critical care is virtually impossible. This problem has hamstrung many potential 99291 claims, according to Edelberg.

"Some physicians I talk to say they don't know what's included in critical care, which makes counting up the time very difficult for coders," said Edelberg during a recent audioconference on documenting hospital services (http://www.audioeducator.com).

Key: Documentation must support that critical care services were medically necessary and reasonable. You can report critical care services for the time the physician spent evaluating, providing care and managing the critically ill or critically injured patient's care. The physician must spend the time at the immediate bedside or elsewhere on the floor or unit, provided the physician is immediately available to the patient.

For example, you may report time spent reviewing laboratory test results or discussing the critically ill or critically injured patient's care with other medical staff in the unit or at the nursing station on the floor as critical care, even when the service does not occur at the bedside, if this time represents the physician's full attention to the critically ill or injured patient's management.

Remember to Count Counseling, Record-Taking

For any given period of time spent providing critical care services, the physician must devote his full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

Scenario: Edelberg notes that sometimes, many doctors won't initially think they provided critical care. "But then if you ask them what they did during the encounter they say: -Well, I spent 30 minutes stabilizing the patient, seven minutes discussing the patient with the family, and 20 minutes recording the details of the encounter," explained Edelberg.

Based on the above description, the physician might have provided critical care. But if the physician records none of this information in the medical record, the coder cannot count these activities toward critical care time.

What's not included is also important. CPR, chest tubes, wound repair, etc., are separately billable. "However, it's important the physician and coders understand what -separately billable- means so that the critical care time that is documented is accurate and includes/excludes services correctly," explains Edelberg.

(For a list of procedures that are included in critical care, check out the explanation in CPT 2008 under the "Critical Care Services" subhead.)

Best bet: Educate your physicians on what's included in critical care time, and encourage them to write down any activity they perform toward patient treatment. That way, the coder will have all the information she needs to make the critical 99291 decision.

Overlapping Time a No-No on Concurrent Care

Transmittal 1530 also spells out Medicare's concurrent care coding rules. Physicians from different specialties can provide critical care on the same calendar date to the same patient provided the services are not "duplicative."

"The medical specialists may be from the same group practice or from different group practices," the transmittal states. Provided the physicians are not billing for the same time block, they can each report critical care they provide for the same patient, Pohlig confirms.

"Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient," according to the transmittal.

Example: Family physicians A and B both work for Family Medicine Practice C. Dr. A provides a patient suffering from acute pulmonary edema and hypotension with 45 total minutes of critical care (from 9-9:30 a.m. and from 11-11:15 a.m.). Later in the day, Dr. B checks up on the patient and ends up providing another 35 minutes of critical care (3:15-3:50 p.m.).

Medically necessary critical care time can be noncontinuous. Therefore, Drs. A and B should both be able to report their time, provided both FPs clearly state the timeframes they provided critical care. Because a claim for 99292 requires 99291, you should report the critical care service on one claim. To account for both physicians- time (total of 80 minutes), you would enter one unit of 99291 and one unit of 99292 using the same group identification number.

Exception: Medicare may cover concurrent care by more than one physician (generally representing different physician specialties) if the requirements in the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, section 30.E are met.

So if a cardiologist and FP provide critical care services that warrant the physician's subspecialty (cardiology) and FP expertise, then concurrent critical care may be medically necessary -- and therefore payable.