Pulmonology Coding Alert

CMS transmittal clears up family counseling, concurrent care rules

To capture valuable critical-care time each time the pulmonologist provides it, coders need to spot critical care indicators -- and doctors need to be diligent about documenting encounter specifics.

CMS released transmittal 1530 on June 6 (http://www.cms.hhs.gov/Transmittals/downloads/R1530CP.pdf), which helps providers with this process. 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 7, 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]).

Check Out 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 pulmonologist meets for three minutes with a patient's wife to give her an update, this cannot be counted as critical care time.

Exception: When the patient is unable or too cognitively impaired to give a medical history or make treatment decisions, you can count time spent consulting the family toward critical care. You can also include time spent discussing treatment decisions, if the pulmonologist has to ask a family member about any allergies to medications, for example.

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."

Important: Family meetings must occur on the patient's unit/floor so the physician remains immediately available to the patient. Discussions that take place in another location are included in the pre- and/or post-service work associated with critical care.

You cannot count any interactions with family members that do not meet the above criteria, warns Catherine Brink CMM, CPC, CMSCS, president of Healthcare Resource Management in Spring Lake, N.J.

"All other family discussions, no matter how lengthy, may not be counted toward critical care," the transmittal states. "Telephone calls to family members or surrogate decision-makers may be counted toward critical care time" -- provided the interactions meet the same criteria as face-to-face family counseling encounters.

Show Physicians the Value of Documentation

To accurately compile critical care minutes, the pulmonologist will have to observe the above documentation requirements for family counseling. The pulmonologist also needs to be diligent about documenting the other critical care components; often, the physician does not provide enough information in progress notes to justify critical care coding.

"Critical care is commonly performed but underreported. I believe many (physicians) often miss critical care coding opportunities," says 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 a patient with a critical illness or injury. If the physician performs activities that count toward that time, but does not include them in the documented time, then it's virtually impossible to capture it appropriately.

"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 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 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/injured patient's management.

Don't miss: 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. 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 when you provide them and critical care. "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.)

Time Overlap Usually a No-No on Concurrent Care

Transmittal 1530 also spells out CMS rules for coding concurrent care, stating that physicians from different specialties can provide critical care on the same calendar date to the same patient -- as long as the services are not considered "duplicative."

"To me, 'duplicative' would be two physicians from different specialties providing the same type of treatment," says Brink. When coding for concurrent care, "the medical specialists may be from the same group practice or from different group practices," the transmittal states.

But both physicians cannot report 99291 for the same "hour" of care. "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.

Check Manual for Concurrent Care Guidelines

Medicare may cover concurrent care by more than one physician (generally representing different physician specialties) if the requirements listed in the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, section 30E and this transmittal are met, confirms Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting, Inc., in Lansdale, Pa.

For instance, if a cardiologist and a pulmonologist provide critical care services that warrant both physicians' expertise (such as congestive heart failure), then medically necessary concurrent critical care for the same date may be payable. Diagnoses can lend to the necessity of each specialist's service. Each physician reporting critical care time for a given date should identify on the claim form the primary condition he is managing.