Pulmonology Coding Alert

Ensure thorough documentation to facilitate optimum reimbursements.

When a patient suffers from a critical illness or an injury such as acute respiratory failure, your pulmonologist might provide critical care services that involve a high level of complex decision making to assess, manage, stabilize the patient and prevent a further deterioration of the patient's life-threatening condition. Use this coding refresher to arm yourself with indicators you will need to capture your pulmonologist's critical care services.

Assess Patient's Condition to Know if Critical Care can be Reported

Ensure that the patient's condition qualifies as critical. CPT® guidelines state that "critical care is the direct care provided by a physician to critically ill or injured patient" and "the critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition." CMS states that "Critical care services must be medically necessary and reasonable" and if services provided are not in accordance to the definitions of critical care services, then an appropriate E/M code should be used to report the services provided (e.g., CPT® codes 99231-99233, Subsequent hospital care, per day...). For more details, check http://www.cms.gov/manuals/downloads/clm104c12.pdf.

When your pulmonologist provides critical care services, you report these services provided with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 30-74 minutes of services provided.

For any additional time that your pulmonologist provides these services, you would use +99292 (Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes [List separately in addition to code for primary service]) for every additional 30 minutes.

Calculate Accurately Time Spent on Providing Critical Care

When your pulmonologist provides critical care for a patient, the notes need to show more than support for the patient's critical status. "Critical care services is a time based service. The billing provider must document the total time spent evaluating and treating the critically ill patient," says Mary Mulholland, MHA, RN, CPC, with University of Pennsylvania Health System in Philadelphia. "Time counted towards critical care services may be continuous or intermittent. The provider must devote his full attention to the individual patient and cannot render care (an E/M or any other service) to any other patient during the reported time period."

"During this time the physician must devote full attention to the particular patient. This time may be spent at the patient's immediate bedside or elsewhere on the unit, so long as the physician is immediately available to the patient," says Mary I Falbo, MBA, CPC, President of Millennium Healthcare Consulting, Inc. in Lansdale, PA. So you need to document all the time spent that comes under the purview of critical care, for example, at bedside, discussion of the case with other staff, time spent with family recording history or making management decisions and reviewing results.

"Time spent performing allowed billable services should not be included (e.g., Insertion of an arterial line)," says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. "Time spent performing bundled services (reading an ECG, starting an IV or looking at chest x-rays or CT) should be included in the critical care time, if performed on the patient's floor/unit."

Observe Timing of Other E/M services Provided on Same Calendar Date

You will need to know when you can report E/M services and critical care services provided by your pulmonologist to the same patient on the same day. "When the provider performs both an E/M service (outpatient or inpatient service) and critical care on the same calendar day, both services may be reported, as long as the E/M service preceded the critical care service," says Mulholland. "Providers are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims," says Falbo.

Here is a coding example that Plummer shares:

"A patient hospitalized with acute exacerbation of chronic bronchitis was seen in the morning for a level 2 subsequent hospital visit. The patient had been recently treated as an outpatient for pneumonia. The patient's condition deteriorated and he went into respiratory failure. The patient was moved to the MICU requiring 60 minutes of critical care time. Code 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components...) with modifier 59 and 99291 for the day's efforts. A 59 (Distinct procedural service) modifier should be used to indicate that the critical care services were totally separate from the earlier E/M service."

Capture Critical Care Services Provided by Different Specialties

To support the necessity of critical care services provided by every specialty, the documentation should carry the date and time of services provided by the concerned specialties. However, you need to note that providers belonging to the same group can provide critical care services as long as they belong to different specialties and services provided are not duplicative.

Crucial: "Medically necessary critical care services provided on the same calendar date to the same patient by physicians representing different medical specialties that are not duplicative services are payable," states Falbo. "The concurrent care by each physician must be medically necessary, and not provided during the same time period, in order to ensure these services are eligible for separate reimbursement," adds Mulholland.

The coding scenario, shared by Plummer, illustrates:

"A pulmonologist provides 50 minutes of critical care from 0900-0950 and codes 518.81 (Acute respiratory failure). A cardiologist provides 35 minutes of critical care from 1100-1135 and codes 428.0 (Congestive heart failure unspecified). Both can bill 99291 and assign their corresponding diagnosis code representing the primary condition they are treating."