Pulmonology Coding Alert

Question: A pulmonologist recently attended to a patient with chronic asthma in the intensive care unit (ICU). I reported 99291 for this encounter and was denied. Is this because the doctor did not spend more than 30 minutes at the bedside?

Alabama Subscriber

Answer: First, check your diagnosis code. Expect denials if the ICD-9 codes do not reflect the severity of the patient's condition to warrant critical care services. If you reported 493.20 (Chronic obstructive asthma; unspecified) the payer may not have felt that the patient met critical care criteria. It is more likely that the case would meet critical care criteria with a diagnosis of 493.22 (Chronic obstructive asthma with [acute] exacerbation), if the patient was indeed experiencing an exacerbation.

Even in light of an "exacerbation," make sure the diagnosis is indicative of a condition warranting the physician's attention for at least 30 minutes. Consider this Medicare definition of critical care:  "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."

Remember, however, that "constant physician attention" does not necessarily mean you can count only the time the pulmonologist was at the patient's bedside toward critical care. You also can count the time the pulmonologist spends reviewing laboratory test results, discussing the critically ill patient's care with other medical staff in the intensive care unit, or at the nursing station on the floor, even if it does not occur at the bedside.