Pulmonology Coding Alert

Question: We have a critical care claim involving a patient in respiratory distress in which the pulmonologist's documentation meets all critical care documentation guidelines except the total critical care time provided. On the template, he circled "critical care" but didn't note the actual time spent.

Should I send this chart back to the pulmonologist for completion, or should I use it as an educational tool for future use and just report a high-level service? My concern is that the payer may view sending the chart back for an addition of time as adding documentation for reimbursement purposes only.


Illinois Subscriber

Answer: You have the option to send this chart back to the pulmonologist for clarification. Many compliance plans allow critical care clarification in this scenario, so you shouldn't get into trouble with a payer as long as you have the documentation you need.

The care of a critically ill patient is very demanding, action-oriented, and occasionally chaotic. If every aspect of the chart isn't absolutely perfect during the course of stabilizing a critically ill patient, this is reasonable because the pulmonologist's attention is focused on the urgency of the patient's treatment.

You should differentiate between adding history-of- present-illness elements (in effect, changing the history) and accurately attesting to what the pulmonologist performed.

With addition of a critical care attestation, you are stating retrospectively what the pulmonologist did - you are not beefing up the history, physical examination, or medical decision-making elements.

Think of this additional information as a clarification that allows you to code the chart accurately, especially when reporting 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]).

Tip: In order to "addend" the chart appropriately, you should date the entry using the current calendar day (not the date of the encounter), document the missing information, and sign the entry. 

You can also add a brief statement of explanation, such as, "Time spent during service inadvertently left out." 

Insurers and legal representatives may question the timeliness of the late entry as well. If you date the entry in a reasonable amount of time (such as, one-two weeks from the encounter), it may be easier to justify. 

If the date on the late entry is much later (such as, two-three months from the encounter date), the insurer or legal entity can question the reasonableness of the entry, the pulmonologist's ability to recall acute information, and the intent of the entry.

If your pulmonologist chooses not to addend the record, bill the code category that best reflects the documentation provided. 

For example, for high-level subsequent hospital care (99233), not only does the patient's condition and pulmonologist's documentation have to reflect high- complexity decision-making, but the pulmonologist must document a detailed history or exam.