Pulmonology Coding Alert

Physician preventing further deterioration is key to valid critical care claims.

What does critical care documentation need to contain to withstand scrutiny? The service itself has to meet CPTs time parameters, patient condition, and physician actions requirements.

To make checking encounter notes for these items easier, get solutions to critical cares who, what, and where?

Who Qualifies for Critical Care?

To report 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]), the pulmonologist must be treating a patient that is critically ill or injured, confirms Rebecca Parker MD, FACEP, president of Team Parker LLC, a coding, billing, and compliance consulting firm in Lakewood, Ill.

CPT classifies a critical illness or injury as acute damage to one or more of the patients vital organ systems, Parker explains.

Critical care also involves high-complexity medical decision making in assessing and supporting those vital organ systems to prevent the patient from getting worse, says Shelley Bellm, CPC, coder at Colorado Mountain Medical.

Critical care requires the highest level of physician preparedness to intervene urgently. Failure to intervene would likely result in clinically significant or lifethreatening deterioration, explained Kenny Engel, CPC, coding coordinator with Advanced Healthcare in Germantown, Wis., during his recent Coding Institute audioconference Critical Care Reporting (www.codinginstitute.com).

If the patient is suffering from one or more of the following conditions, then your pulmonologists service should qualify as critical care, writes Stephen R.Levinson, MD, in Practical E/M: Documentation and Coding Solutions for Quality Patient Care:

" Failure of the central nervous, circulatory, or renal systems

" Shock

" Hepatic, metabolic, or respiratory failure.

Caution: Before you can consider billing for 99291, the pulmonologists treatment time must be 30 minutes or longer. This time parameter is inflexible, according to Levinson.

If the pulmonologist spends less than 30 minutes of critical care time on a particular day, regardless of the severity of patient illness and complexity of decision making and treatment, an appropriate E/M code must be submitted instead of 99291, Levinson writes.

This time does not need to be continuous, says Parker -- but it does need to add up to at least 30 minutes before considering 99291.

Whats Included in Critical Care?

If your pulmonologist provides any of the following services during critical care, do not code them separately, as they are included in 99291 and 99292 services. When totaling critical care time, the 2009 CPT manual states that you may include the time for procedures the physician cannot bill separately, such as:

" Interpretation of: cardiac output measurements(93561, 93562); x-rays (71010-71020); pulse oximetry (94760-94762); blood gases, and information data stored in computers (such as ECGs, blood pressures, hematologic data [99090])

" Gastric intubation (43752, 91105)

" Temporary transcutaneous pacing (92953)

" Ventilatory management (94002-94004, 94660, 94662)

" Vascular access procedures (36000, 36410, 36415,36591, 36600).

If the physician performs procedures that are not listed above, report them separately from 99291, and do not include the associated time in the cumulative critical care time. Examples of services that are excluded from critical care include: endotracheal intubation, pericardiocentesis,and central venous catheter placement.