Wiki Critical Care requirements for Neurologists

[mhstrauss]

My neurologists that see patients at a nearby hospital (usually being consulted on ER cases) have a question about requirements for billing Critical Care (99291-99292). I've given them the guidelines from the current CPT book that state that "providing medical care to a critically ill, or injured, or post-operative patient qualifies as a critical care service only if both the illness or injury AND the treatment being provided meet the above requirements". They are arguing that at times, the patient's illness meets the critical guidelines, but no treatment is given. Based on the book guidelines, this would not meet the CC guidelines, but they feel that the intensity of the service/severity of the patient's condition should still meet the guidelines. Some examples are if the patient is in status epilepticus, myasthenia gravis crisis, hypoxic brain injury due to cardiac arrest, encephalitis. The most common example of when they do meet the CC guidelines is stroke patients who have TPA ordered. Can anyone give any insight or documentation that would agree with their opinion that these patients qualify for CC codes even though they don't meet the book guidelines?

TIA!!

 

[thomas7331]

Maybe I'm not completely understanding your physicians' opinion, but it seems to me you're asking a bit of a circular question of how the code description could be met by some means other than by meeting the description given for that code.

I think CPT is pretty clear that the treatment referred to 'involves high complexity decision making to assess, manipulate and support vital system function(s)' and that this is a required component of the service represented by this code. If 'no treatment is given' then there is no treatment 'there' to meet this requirement - how can you manipulate and support vital system functions without administering treatment? Critical care is an intervention to stabilize a patient in order to save their life - if there is no treatment, then what services exactly are the physicians providing that they think should meet these definitions?

 

[mhstrauss]

Maybe I'm not completely understanding your physicians' opinion, but it seems to me you're asking a bit of a circular question of how the code description could be met by some means other than by meeting the description given for that code.

I think CPT is pretty clear that the treatment referred to 'involves high complexity decision making to assess, manipulate and support vital system function(s)' and that this is a required component of the service represented by this code. If 'no treatment is given' then there is no treatment 'there' to meet this requirement - how can you manipulate and support vital system functions without administering treatment? Critical care is an intervention to stabilize a patient in order to save their life - if there is no treatment, then what services exactly are the physicians providing that they think should meet these definitions?

Thank for your reply, Thomas. I completely agree with you - lack of treatment means that they do not meet the guidelines. But I was asked to post the question during a discussion about this at a recent department meeting, so here I am.

In some cases, no treatment is given because the patient doesn't qualify for it, for example TPA, if the patient is past a certain time window since first symptoms, they do not qualify to receive TPA. I'm not sure of other examples.

I appreciate your input.