Pulmonology Coding Alert

Question: I've heard that the pulmonologist doesn't need to be in the room with a critically ill patient to bill 99291 for critical care time -- is this right? Also, can you clarify what the severity threshold is for critical care?

Answer: According to CPT, a patient must be critically ill or injured to qualify for critical care services.Critical illness or injury is defined as impairment of one or more vital organ systems creating a 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. According to 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 the cumulative 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 patient's floor would be reported as critical care, even if it does not occur at the bedside," Medicare states.

Consider this example: The pulmonologist evaluates 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 requiring intubation.

The physician clearly documents that he 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, and

• 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.