Pulmonology Coding Alert

Patient condition, not location, drives proper coding When your pulmonologist provides critical care outside the emergency department or other designated "critical care area," your claim will be snag-free, provided you meet two important documentation requirements: time and severity Important: A patient who receives critical care "does not actually have to be in a critical care location," says Jacquelyn Dodge, a receptionist and coder at Eric A. Wingerson, DO, in Idaho Falls. Keep good records, and most payers will reimburse 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]).
Do: Code Critical Care in Non-Traditional Settings If you think that your physician has to be in an emergency department (ED) or other designated "critical care area," you may be missing out on well-deserved reimbursement. In other words, no matter the setting, critical care is based on the physician's time spent caring for the critically ill or critically injured patient, meaning there is a high probability of imminent or life-threatening deterioration of the patient's condition, experts say. Resource: To get the whole definition of critical care, you should check out the CMS manual at the following URL: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Although most critical care occurs in an emergency department or other designated "critical care area," Medicare pays for critical care provided in any location if you meet the requirements. Conversely, a patient's presence in an intensive or critical care unit doesn't solely justify critical care billing.
Don't: Skimp on Your Critical Care Documentation Although the critical care may have occurred in a non-traditional setting, the service is still a viable critical care claim -- as long as you meet documentation requirements, experts say. "Whether a service meets critical care requirements depends on treatment, complexity of care provided, severity of the patient's condition, and physician documentation," says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City. In critical care, location is secondary to documentation. Heed this advice: To lock up reimbursement for your critical care claims, check out this short list of tips on documentation:
1. Note time for the critical care services. Document "start and stop" or cumulative time spent on all care the physician provides on a given calendar day. If the pulmonologist provides critical care and another service in the same session, specifically exclude minutes spent rendering separately billable procedures and indicate in the note that the critical care time does not include procedure time. 2. Detail all the services the physician provides. These services would include the usual E/M components. Other services that may (or may not) be part of a carrier's [...]