Pulmonology Coding Alert

Remember to count bundled services toward critical care time

When the pulmonologist treats a patient with a serious injury or medical condition, coders should be on the lookout for possible critical care services. After all, these codes sport higher relative value units (RVUs) than the  standard E/M codes.

But be careful you don't miscode a claim in your zeal to use the high-RVU critical care codes. You'll have to prove that the patient needed critical care services before considering 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (... each additional 30 minutes [list separately in addition to code for primary service]), or you'll likely receive a denial for your claim.

Establish Critical Illness or Injury First

According to CPT, a patient must be critically ill or injured for critical care services.

Critical illness or injury is defined as impairment of one or more vital organ systems such that there is risk of imminent or unstable life-threatening deterioration in the patient's condition.

Critical care involves high-complexity medical decision-making to assess and support the functionality of vital organ systems--all in an effort to prevent the patient from deteriorating further, says Shelley Bellm, CPC, coder at Colorado Mountain Medical.

Translation: Critically ill or injured patients require immediate medical attention, or they will get worse--or die, says Michael Lemanski, MD, billing director at Baystate Medical Center in Springfield, Mass.

Check out this definition from Medicare: "Critical care includes the care of critically ill and unstable patients who require constant physician attention, whether the patient is in the course of a medical emergency or not."

But "constant physician attention" does not necessarily mean constant physical contact with the patient. When you report critical care time, Medicare wants you to report "the time the physician spent working on the critical care patient's case, whether that time was spent at the immediate bedside or elsewhere on the floor, but immediately available to the patient."

So time spent "reviewing laboratory test results or discussing the critically ill patient's care with other medical staff in the unit or at the nursing station on the floor would be reported as critical care, even if it does not occur at the bedside," Medicare states.

Consider this example: The pulmonologist meets a 67-year-old established patient with chronic obstructive pulmonary disease (COPD) at the hospital. The patient is in severe respiratory distress with an acute exacerbation of his underlying lung disease. Despite multiple rounds of nebulizers, treatment with steroids, and additional supplemental oxygen, the patient develops worsening respiratory distress and ultimately suffers acute respiratory failure and requires intubation.

The physician documents that she spent 45 minutes of time outside of separately billable procedures caring for this critically ill patient.

On the claim you would report the following:

• 99291 for the critical care
• modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99291 to show that the critical care and intubation were separate services
• 31500 (Intubation, endotracheal, emergency procedure) for the emergency intubation
• 518.81 (Acute respiratory failure) and 491.21 (Obstructive chronic bronchitis; with [acute] exacerbation) linked to both 99291 and 31500 to prove medical necessity for the encounter.

Observe Critical Care Bundles

As shown in the above example, some services are separately reportable from critical care. In addition to CPR, here are the other services that you may report separately from 99291 and 99292:

• endotracheal intubation
• pericardiocentesis
• central venous catheter placement
• arterial line placement.

However, the following services are bundled into 99291 and 99292:

• interpretation of cardiac output measurements
• interpretation of pulse oximetry
• interpretation of data stored in computers
• transcutaneous pacing
• ventilator management
• some vascular access procedures
• gastric intubation.

Suppose you're reviewing progress notes indicating that the physician provided critical care. During the session, the physician performed endotracheal intubation and ventilator management.

On the claim, you should report the intubation separately, but you should consider the time spent managing the ventilator and related issues as part of critical care time.

Document Total Critical Care Time

Remember that critical care encounter time need not be continuous, says Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla. When compiling critical care time, you should count the total time the physician provided his full attention to the care of the critically ill or injured patient on a single date of service, Edelberg says.

"That would include time spent documenting the critical care patient's record, speaking with family or other healthcare providers, treating the patient, giving orders for treatment, etc.," Edelberg says, as long as these services occur on the patient's floor or unit. If the family discussion occurs in the physician's office, it does not count toward critical care time.

Documenting these actions in the medical record is vital to the health of your critical care claim. It will help support critical care services and medical decision-making, in addition to meeting the time requirements for 99291.

Critical care time does not, however, include time the physician spends treating other patients, or time spent performing other billable procedures for the critically ill patient. So if the physician performs CPR, which is separately billable, the physician cannot count that time toward total critical care minutes.

Example: The pulmonologist provides 45 minutes of critical care for a patient in the morning. The patient's condition stabilizes, and the physician tends to other patients at the facility. Later that afternoon, with the patient's condition deteriorating, the pulmonologist returns to provide 20 more minutes of critical care.

In this instance, the physician provided 65 minutes of noncontinuous critical care. On the claim, report 99291.

Drop Location Concerns for Critical Care
 
Remember that critical care can occur wherever the physician performs critical care on a patient--the patient does not need to be in the intensive care unit (ICU) or emergency department. What drives critical care is the patient's condition, not the location, Edelberg says.

However, if the physician provided care in an unusual location (office or clinic), the payer may require documentation "explaining the unusual place of service for such a high-acuity treatment," Edelberg says.

Best bet: If you have that rare claim in which the pulmonologist performs critical care outside of the hospital setting, gather all of the necessary documentation to support your claim, and provide a copy to the insurer when it is requested.

Conversely, suppose the physician treats a patient in a location where critical care is common, such as the ICU. This is not a guarantee that critical care occurred; you'll have to check the encounter notes before deciding whether to use 99291-99292.

According to Medicare: "Services for a patient who is not critically ill and unstable but who happens to be in a critical care, intensive care, or other specialized care unit are reported using subsequent hospital care codes (99231-99233) or hospital consultation codes (99251-99255)."