Pulmonology Coding Alert

Reporting critical care on the same day as other services or procedures can be near impossible, but you can learn proper coding guidelines that will enable you to break the gridlock on these claims. The problem occurs because critical care coding guidelines are stringent when it comes to the documentation needed to support medical necessity and to show that multiple services are warranted. Since a doctor's time spent with critical care patients is often complex and in-depth, it is hard to sift through the rules pertaining to time spent with patients, coverage of specific procedures, and medical necessity. Therefore, you need to be clear on what is required in order to get proper reimbursement for your time spent with critical care patients. Coding for Multiple E/M Visits on the Same Day It is often necessary to provide critical care services on the same day as other E/M services. Although tricky, it is possible to bill for both services on the same day and get full reimbursement. According to Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm based in Lansdale, Pa., documentation and careful coding are the keys to billing for multiple E/M visits. You need to follow a few simple guidelines to optimize your reimbursement. For example, a patient is admitted in the morning for asthma and, later in the day, goes into respiratory arrest. You would "bill the hospital admission code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of other service) and add up all of the time spent on critical care, and bill the codes (99291-99292) accordingly," says Renee Brown, CPC, Southeastern Lung Care, Conyers, Ga. Make sure to distinguish between the two services by using different diagnosis codes.

According to Falbo, an important tip is to associate the most specific diagnosis code that explains the critical care condition with the critical care service. The level of specificity is important because payers do not see progress notes. The linkage of codes that support medical necessity for critical care is important so that the payers, upon review of the documentation, do not downgrade the critical care service to a subsequent hospital care visit. The diagnosis codes from the 493.xx series (Asthma) would match the hospital inpatient code (99221-99233), and the respiratory arrest code (799.1) would match the critical care code (99291-99292). There may be circumstances in which the physician sees a patient in an outpatient setting for a regular office visit and later sees the patient for critical care. For example, a 65-year-old woman undergoes an exam for emphysema. The exam is completed, and she is sent home. [...]