Pulmonology Coding Alert

Insufficient physician documentation not your coding skills could be jeopardizing reimbursement for your critical care claims.

Tell your doctors about the payment they sacrifice if they don't understand when and how to document critical care, says James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa. and then help them out with the information below. 'High Probability' Opens Reimbursement Doors Critical care may cover more services than you or your physicians think it does.

Critical care services include the direct delivery of medical care to a critically ill or injured patient, says Deborah Grider, CPC, CPC-H, CCS-P, CCP, president of Medical Professionals Inc. in Indianapolis. A critical care patient must have the "high probability of imminent or life-threatening deterioration," according to CPT.

But don't overlook the phrase "high probability" that's what could increase your revenue. A patient doesn't have to be on her deathbed to require these services. The necessary condition is the risk for, not the presence of, instability. "Physicians so often fail to document critical care time on patients whose condition could deteriorate rapidly into a life-threatening situation," says Nettie McFarland, RHIT, CCS-P, at Healthcare Billing Systems Inc. in South Daytona, Fla.

Here's an example of when your pulmonologist provides critical care services, reported 99291 ( first 30-74 minutes) and +99292 ( each additional 30 minutes), for a patient who never technically becomes unstable. The physician provides care for the patient with a severe allergic reaction who has hives and is wheezing. The patient then develops stridor (786.1) but does not have respiratory failure, although the imminent potential is very real.

In this case, the presenting problem not the final diagnosis or condition determines the risk factor of the case. The severe allergic reaction presents the potential for an unstable, high-risk condition, so diagnosing and treating the crisis warrants critical care codes. Note, however, that almost all allergic reactions would not qualify as critical care because in most cases the physician only has to administer an antihistamine and maybe a breathing treatment.

Here's a useful rule of thumb for determining critical care status. For you to report critical care, the patient must be on a medication or a treatment regime that is supporting an organ system, and without that treatment the patient would be unstable, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. This approach will keep you from over-reporting critical care. Watch Your Documentation Documentation is the saving grace of critical care payment. Review your documentation completely before using it to support critical care codes, McFarland says.

Check that documentation covers the site of service, medical necessity and services provided, Grider [...]