Pulmonology Coding Alert

Question: When our pulmonologist rounds on a patient in the critical care unit (CCU), can we use the critical care E/M codes for the encounter?

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Answer: You can if the rounds meet the critical care criteria, but you won’t always use these codes just because the physician sees a patient in the CCU. To use the critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and, if needed, +99292 (… each additional 30 minutes (List separately in addition to code for primary service)), the service must occur when it’s required, not conveniently on rounds. Being in the critical care unit does not necessarily warrant a critical care code. For example, some hospital protocols require that specific medications can only be administered in an ICU for the patient to be monitored more frequently by nursing staff. This does not represent critical care.

To use the critical care codes, the patient must be critically ill or injured, requiring urgent care for a life-threatening condition. Also, the physician must use high-complexity decision making to address the condition, and the service must be at least 30 minutes within the same day. During that time, the physician must be available to the patient and engaged directly with the patient’s care.

Therefore, you shouldn’t automatically report a critical care code just because a patient is in the critical care unit. If your pulmonologist’s visit is to see a patient for subsequent hospital care instead of for critical care, you’d instead report a code from the 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …) range.