Pulmonology Coding Alert

Question: We disagree with our pulmonologist's documented level of care for one of his critical care patients. The physician documented critical care time minutes, but upon review of the medical record, we don't think the patient's condition warrants this level of care or meets the requirements for administering critical care. We want to code the report as a high-level E/M service. Can we or should we code for a different service than the physician chose to perform?

Pennsylvania Subscriber

Answer: If you question the necessity or length of the critical care time your physician provided, you should probably review the patient record with the physician. You should then code according to the reviewed decision. Before you send out the claim, document somewhere on it that the physician reviewed the chart.

Before you go into the review with your physician, make sure you know exactly why you want to change critical care to the highest-level initial hospital care code (99223). Check your critical care guidelines. The language in this section of the CPT manual has changed over the past few years. Remember, a patient's condition warrants critical care even if the danger isn't now threatening the patient's life. The guidelines state that a critical illness or injury is one that "acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration" (emphasis added). For more on this topic, see "Resuscitate Critical Care Payment: Educate Physicians"

You Be the Coder and Reader Questions reviewed by Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Questions answered by Deborah Grider, CPC, CPC-H, CCS-P, CCP, president of Medical Professionals Inc. in Indianapolis.