Pulmonology Coding Alert

Question: A patient goes into respiratory arrest during a routine exam for emphysema and moves into a critical-care state. How is the determination made between the previously stable condition and the critical one? Which codes apply? Is there a time period that a patient must be critical?

Maine Subscriber  
Answer: Critical care is the direct delivery of medical care for the critically ill/injured patient. A critical illness/injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patients condition.  Critical care involves high-complexity decision-making usually to prevent further life-threatening deterioration of the patients condition. It is not necessary that critical-care services be rendered in a critical-care setting, such as an ICU. And the same physician may provide critical care and other E/M services to the same patient on the same day. 
 
In this example, if the physician had completed the requirements for reporting an office visit (two of the three key components: history, exam and medical decision-making) before the patient became critically unstable, an office visit could be billed (99201-99215). This can only be done if the E/M service was performed and completed prior to the critical-care service. Otherwise, all of the services would be considered a part of, or included in, the critical-care management.  
 
For you to bill the critical-care service, the patients care must meet the critical-care definition described above and the time requirements. Code 99291 requires 30-74 minutes of critical care to be rendered. Anything less than 30 minutes would require the appropriate E/M code. Code 99291 can be used only once per day and would be used as the initial code. 99292 is always used in addition to 99291 and never by itself. It signifies critical-care services in additional 30-minute intervals after the first 74 minutes. For example, 99292 is used in addition to 99291 for 75-104 minutes of critical care, 99291 and 99292 x 2 are for 105-134 minutes of critical care, 99291 and 99292 x 3 for 135-164 minutes and so on. This is not to total more than 24 hours per calendar date.
 
The critical-care time in the above case would begin when the patient became critically unstable. A different diagnosis would be used to identify each separate service. Respiratory arrest (799.1) is linked to the critical-care service, and emphysema (492.0-492.8) is linked to the office visit. Modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) must be appended to the office visit to alert the carrier that this is a separately identifiable service from critical care.