Pulmonology Coding Alert

Time always tells all for 99291 and 99292 If you struggle with reporting critical care, look to the pulmonologist's documentation and details on how much time he allotted for every step of his services to lead you to the correct coding choices. First Step: Determine If the Patient Is 'Critically Ill' Before you can tackle choosing the correct code for your critical care procedures, you must first decide if the pulmonologist delivered actual "critical" care services.

Begin by looking at the documentation to see whether  the patient's condition warranted critical care services from the pulmonologist.

If a patient has an illness or injury that impairs one or more vital organ systems and poses an imminent or life-threatening threat to the patient's condition, the patient is critically ill, according to CPT. When the pulmonologist provides critical care to these patients, the care involves:

high-complexity decision-making
assessment, manipulation and support of vital system functions
treatment of single or multiple vital organ system failures
overall prevention of organ failure and further life-threatening deterioration.

If you can determine that a patient is critically ill based on these criteria, you've accomplished the first step to correctly reporting 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]), says Michele Wendling, billing manager with Midwest Medical Services in Troy, Ohio.

Example: Your practice admits a patient with severe chest pains. The pulmonologist discovers that the patient has blood clots in the deep veins of his leg. These blood clots require immediate, constant and high-level attention. For four hours following admission, the patient shows signs of pulmonary hemorrhage that requires a high level of physician preparedness and intervention. This level of care qualifies as critical care, coding experts say.

However, when the patient's condition stabilizes such that the immediate threat of death or loss of significant function is unlikely and the physician no longer provides frequent attention and management, you may no longer claim critical care, Wendling says.

Coding solution: In the above example, you should report the first 74 minutes of care using 99291. You may report the remaining 2 hours and 46 minutes using 99292 x 6.

If the pulmonologist performs any separately reportable procedures at the same time (such as 92950, Cardiopulmonary resuscitation [e.g., in cardiac arrest]), you should append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the critical care codes to identify them as separate procedures from the CPR, Wendling says.

Remember: You should subtract the time the pulmonologist spent performing 92950 from the critical care time. [...]