Pulmonology Coding Alert

Patients with respiratory acidosis may require critical care. If the pulmonologist satisfies all the CPT requirements for providing such care, he or she can expect much higher payment than by reporting the individual treatment options, such as ventilator management (94656).

The pulmonologist should report the critical care codes (99291-99292) for directly delivering medical care to the critically ill or injured acidosis patient that includes high-complexity decision-making to assess, manipulate and support vital organ system failure and/or to prevent further life-threatening deterioration of the patient's condition. Use 99291 for the first 30-74 minutes of critical care, and 99292 for each additional 30 minutes.

Critical care can be provided in any setting and involves medical decision-making that is highly complex, often involving manipulation of different systems (e.g., pulmonary, cardiovascular and metabolic functions) to treat single or multiple vital organ system failure, says Mary Mulholland, RN, BSN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. It also includes interpretation of multiple databases, lab and radiology values.

For example, an unconscious patient is brought into the emergency department (ED) in respiratory failure caused by chronic obstructive pulmonary disease (COPD). The ED physician calls in the pulmonologist, who orders an arterial blood gas (ABG) study that reveals respiratory acidosis. The pulmonologist inserts an endotracheal tube and places the patient on a ventilator. The pulmonary physician determines the patient is critically ill and monitors her condition for about 45 minutes until she stabilizes.

The pulmonologist's clinical documentation must describe the critical nature and instability of the patient's condition and the cognitive efforts of the treating physician, Mulholland notes.

Critical care is a time-driven service. "Critical care codes are used to report the total duration of time spent by a physician even if the time spent by the physician is not continuous," Mulholland says. "Therefore the billing provider must document the total time he or she spent in treating the patient."

Critical care time is only the time spent on work directly related to the individual patient's care, regardless of whether that time is spent at the bedside or on the floor or unit, such as reviewing lab results or discussing the patient's care with other medical staff, she adds.

Time spent in activities outside the patient's unit or off the floor may not be reported as critical care. In addition, if the pulmonologist performs separately reportable services, he or she may not include that time when determining critical care billing.

Keep in mind that ventilator management (94656-94657) is bundled into 99291 and 99292 as with any E/M code by the national Correct Coding Initiative (CCI). But, according to CMS' 2002 Physician Fee Schedule, 99291 carries 4.00 work relative value units (RVUs) and 99292 has 2.00 RVUs, whereas 94656 has 1.22 RVUs, and 94657 has 0.83 RVUs. Higher RVUs result in higher reimbursement. However, if you have not spent at least 30 minutes of care directed toward the patient and have not fulfilled the requirements of critical care, you cannot bill for this service. Ventilator management remains an option. But CCI does not bundle the endotracheal tube placement (31500) into critical care or ventilator management, and the procedure may be reported separately.