Pulmonology Coding Alert

The physician's documentation is your key to success

When you receive a denial from a payer for critical care services, you should look back at the pulmonologist's documentation to determine whether you should appeal the denial. At times, insurers will deny legitimate critical care claims.

Examples: A pulmonologist may provide critical care to a patient who is in respiratory arrest, has acidosis from chronic obstructive pulmonary disease (COPD) or has adult respiratory distress syndrome (ARDS), among other conditions.

When a pulmonologist provides services that are considered critical care, check his notes to see:
 
• if documentation includes the patient's condition that necessitated critical care.
• how much time is documented that the physician spent with the patient.

Once you've answered these questions, you can determine whether reporting for critical care services is appropriate.

Follow these expert suggestions to ensure you're filing accurate critical care claims:

Watch for Keywords About Patient Status

Before you code for critical care services using 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]), make sure the physician documented that the patient's condition warrants critical care.

Required: The physician needs to document that the patient is critically ill, which requires that the patient have  at least one organ system that is failing and that the patient's life is in jeopardy. According to CPT, the patient must have "a critical illness or injury [that] acutely impairs one or more vital organ systems" and requires the physician perform "decision-making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple organ system failure, or to prevent further deterioration."

Caution: A patient does not have to be in the intensive care unit to be critically ill, and similarly, not every patient in ICU is critically ill, says Pierre Edde, MD, director of the sleep and respiratory services at Uniontown Hospital in Pennsylvania and founder of www.PCSbilling.com. The key is the "high probability of imminent or life-threatening deterioration in the patient's condition," Edde says.

Time Is a Critical Factor

Critical care time works on a calendar day. The time does not have to be continuous, but you should make sure the physician recorded the time he spends with the patient in the patient's chart and explains everything he did during that time before you report critical care services.

Example: The doctor provides 70 minutes of critical care to stabilize a patient at 11 a.m. Two hours later, the patient's condition worsens and the physician is again called on to provide another 40 minutes or critical care. Even though the service was not continuous, you can still report all of the critical care time.

On the claim,

• report 99291 for the first 70 minutes of critical care.
• report 99292 for the last 40 minutes of critical care.

Don't Rule Out Other Services

If the pulmonologist provides critical care services on the same day that he provides other services, don't automatically rule out billing both. You can bill for another evaluation and management service, such as an initial emergency department or subsequent inpatient visit on the same date you bill for critical care, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Example: The physician sees a patient in the morning and provides subsequent hospital care. Then, in the afternoon, the patient's condition worsens dramatically and the physician provides critical care services. In this example, you can bill for both the critical care services and the subsequent hospital care service (99231-99233), Hammer says.

Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the subsequent hospital care service to indicate that it was significant and separately identifiable from the critical care service.

You can also bill for services that CPT and the National Correct Coding Initiative don't bundle with critical care services, such CPR (92950) or the insertion of a Swan-Ganz line for monitoring (93503).

Be sure not to include the time the physician spends on these additional procedures in your critical care service time, however.

Note: "All of these procedures are considered 000 global days, and it may be necessary, payer-dependent, to indicate that the critical care service was separate and significantly identifiable from the procedures using modifier 25 appended to 99291," Hammer says.