Primary Care Coding Alert

Coding professionals who monitor critical care service codes noticed several significant changes earlier this year. These adjustments increased opportunities for family physicians to report critical care services but, ironically, they also triggered a reduction in the work relative value units (RVUs) associated with these codes.

Last year, critical care specialists recommended that the American Medical Association modify CPT definitions for critical care, in many instances relaxing the circumstances under which they can be assigned. Specifically, services that coders previously reported as subsequent hospital care (evaluation and management codes [E/M] 99231-99236) are now categorized as critical care. The critical care codes modified in CPT 2000 include 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]).

The Health Care Financing Administration (HCFA), which has long kept a close eye on the use of critical care codes, reacted to the adopted changes by reducing reimbursement received for these services. According to Daniel S. Fick, MD, associate professor, residency director and medical director for the Department of Family Medicine at the University of Iowa College of Medicine in Iowa City, the change in critical care RVUs represents a decrease in reimbursement of about 10 percent.

Patient Not Required to Be Unstable

The most significant example of the changes in critical care coding is the deletion of the word unstable from the descriptions for 99291 and 99292. This is a noteworthy change, coding professionals point out, because it includes conditions previously not categorized as critical. In the past, these would have been reported with one of the subsequent hospital care codes (99231-99233).

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., agrees. This new definition relaxes the times when coders can appropriately report these critical care codes. A physician may see a patient who is critically ill or injured, but whose condition may not be defined as clinically unstable. In the past, we could not assign a critical care code for these services. Now we can.

For instance, a patient may be admitted to the intensive care unit (ICU) after a significant cardiac event. His vital signs have normalized, but his condition continues to be critical. In the past, family physician services while treating this patient would have been coded with the appropriate E/M code. Because CPT 2000 has removed the requirement that the patient be unstable, services could now be coded with 99291 for the first 30-74 minutes of care and 99292 for each additional 30 minutes, if all other requirements for critical care services are met (see Defining Critical Care on page 45).

Codes Include Discussions With Family Members

Another new and notable change is in how we can code time spent with the family of critical patients, points out Callaway-Stradley. In the past, it was not clear how we could categorize this time. Now, CPT has clearly stated that it may be included in critical care service.

Generally speaking, coders may assign 99291 and 99292 only when the physician is engaged in work that is related directly to the patients care. This time may be at bedside or elsewhere on the floor or unit, Fick says. For example, it may include time spent reviewing test results or imaging studies, discussing care with other medical staff or documenting critical care services in the medical record.

The language included in CPT 2000, however, also states that critical care services may encompass time spent on the floor with the family members or surrogate decision-makers, he adds. These instances may be reported as critical care, if the patient is unable or clinically incompetent to participate in these discussions. These discussions must have a direct bearing on the patients care and could include reviewing the patients condition or prognosis, obtaining a medical history, or discussing treatment options and treatment limits, he says.

Telephone calls to family members and surrogate decision-makers may be charged as critical care if they meet the same conditions as face-to-face meetings. But providing the family with regular updates on the patients condition, answering questions or providing emotional support do not fit the requirements for critical care services, Fick points out.

Physician Must Provide Full Attention

The new CPT guidelines also clearly outline time requirements for critical care services. According to Fick, CPT previously required that constant attention be paid to a critical care patient. The new language states that the doctor needs to devote full attention to the patient and not to anyone else while billing the critical care code.

The guidelines also state that the time the physician spends with the patient need not be continuous, Fick says. In other words, you can code for the total time spent on different occasions during the same day.

But coders cannot assign critical care codes to activities occupying the physicians time during breaks in the care he is giving the patient. For instance, if a family practitioner stops by to see patient B while waiting for lab results for critical patient A, he cannot bill that time as critical care because he is not devoting full attention to patient A.

I cant emphasize enough how important documentation is with these codes, Fick continues. Physicians need to make thorough notes in the medical record about specifically what sort of care they provided and exactly how much time was involved. These will be the measures that carriers use to determine whether or not the critical care codes are justified. In fact, CPT critical care guidelines now clearly state that the time spent with the individual patient should be recorded in the patients record and outlines all of the appropriate circumstances for counting the time.

Aspects of Critical Care Codes Re-emphasized

Although reflecting some changes, there are other areas where CPT 2000 re-emphasizes those conditions that must be met for critical care codes to be assigned. Among these is the fact that coders may not code by location, Fick says. Some coders may assume that because a patient is seen in the ICU, he or she is a critical care patient. This simply is not true. There are many instances where a family physician may see a patient who has been admitted to intensive care, but renders services that are not classified as critical.

For example, a family physician visits one of his patients who has been admitted to the ICU by a cardiologist. The cardiologist has placed the patient on a ventilator and a nitroglycerine drip. During the visit, the family physician spends 15 minutes evaluating and treating a rash that is bothering the patient. Although the family physician is seeing the patient in the ICU, his services would not warrant assigning a critical care code because treatment of the rash does not meet the CPT definition of critical care.

Instead, coders should report his time with the appropriate E/M code in this case 99231 (subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem-focused interval history, a problem-focused examination, medical decision-making that is straightforward or of low complexity).

In another example, Fick says a physician may see a patient for a heart condition and admit him to the telemetry unit. For the next four days, the physician may round on this patient, but he cannot bill for critical care unless this patient meets the specific requirements defining critical care.

He also adds that critical care is not billable by a teaching physician if he or she is not physically present. Time spent by a resident does not count toward critical care services, he says.

Codes That Are Bundled With Critical Care Services According to Daniel S. Fick, MD, HCFA has listed codes that are included in the critical care service when performed on the same day. These are bundled services and should not be reported separately, he warns. Interpretation of cardiac output measurements (93561, 93562) Chest x-rays (71010, 71015, 71020) Blood gases, e.g., carbon dioxide (82803) Blood draw for specimen (G0001) Information data stored in computers, e.g., ECGs, blood pressures, hematological data (99090) Gastric intubation (91105) Pulse oximetry (94760, 94762) Temporary transcutaneous pacing (92953) Ventilator management (94656, 94657, 94660, 94662) Vascular access procedures (36000, 36410, 36600) Family medical psychotherapy (90846) Other services may be reported separately.

Defining Critical Care The current definition of critical illness or injury states the condition must acutely impair one or more vital organ systems such that the patients survival is jeopardized. In addition, the CPT description for critical care services states that care must be delivered directly by a physician and involve decision-making of high complexity to assess, manipulate and support a variety of complex conditions. There must be a high probability of sudden, clinically significant or life-threatening deterioration in the patients condition that would require the highest level of physician preparedness to intervene urgently. The treatment or intervention requires frequent and personal assessment on the part of the physician. Finally, it allows for interpretation of multiple databases, use of advanced technology and care over multiple days.