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Pulmonology Coding Alert

Mastered Critical Care Coding? Review These Crucial Steps First

Published on Tue Sep 28, 2004

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. You should also subtract any time the pulmonologist spent performing procedures during critical care (arterial or central venous lines) from the critical care time, says Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy and critical care at the Emory University School of Medicine in Atlanta.

    Second Step: Turn to Time to Determine Critical Versus E/M Care

    If a pulmonologist delivers critical care to a patient, he must spend at least 30 minutes administering critical care services before you can justify reporting 99291. 

    Example: You have an elderly patient in your facility who is on a ventilator. One day, you receive a code blue because that patient has ventricular tachycardia. The pulmonologist administered one shock to the patient. From this shock, the patient's pulse and sinus rhythm returned to normal.

    You check the documentation for this procedure, and you find that the pulmonologist did not document cardiopulmonary resuscitation (CPR). The documentation also stated the procedure lasted for 20 minutes. Based on the documentation, you are left with a choice between coding for a follow-up E/M code, the administration of the shock, or cardioversion, says Lisa Center, CPC, quality coordinator with Freeman Health System in Joplin, Mo.

    Bottom line: Because the physician documents less than 30 minutes of care, you cannot bill 99291, Center says.
    Although you may also consider billing 92950 because the pulmonologist administered shock to regulate the patient's pulse and sinus rhythm, you are not justified in billing that either because the physician did not document a CPR procedure, Center says.

    Solution: You should bill 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) based on ruling out the critical care and CPR codes, Center says.

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