Optimize Reimbursement by Coding for Critical Care Services--Regardless of Where Provided

Nugget: Infectious disease physicians can bill for critical care regardless of setting: critical care department, emergency department, or even the physicians office.

Infectious disease (ID) physicians can optimize reimbursement for critical care by realizing that they can provide such services in any setting, including the physicians office. Often providers code critical care based on the location of the patient, says Sally J. Trew, RN, CPC, a medical reimbursement specialist for Alpern Rosenthal & Company, an accounting firm that provides healthcare consulting services, in Pittsburgh. Some providers believe that if a patient is in a critical care unit, they should report their services using critical care codes 99291-99292. This is incorrect, according to Trew. Critical care services can be provided in any setting, including the physicians office.

Critical care is defined by CPT 2000 as the direct delivery by a physician(s) of medical care for a critically ill or injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that the patients survival is jeopardized. According to Trew, there are three essential questions to ask when deciding to use these codes:

Does the patients condition meet the definition of critically ill/injured?

Has the physician spent at least 30 minutes providing direct patient care (this means the physician can not provide any service[s] to any other patient during the same time that is being reported as critical care); and

Does the documentation in the patients medical record reflect his or her critical condition and the services provided by the physician?

The appropriate code for reporting the initial 30-74 minutes of critical care is 99291, Trew says. She points out that this is for cumulative time on any given date the time does not have to be continuous. For each additional 30 minutes on the same date, you should use code 99292. In addition, the total time for physicians of a group practice provided on the same date should be reported as one total.

For example, Trew says, presume ID physician A sees a patient for 30 minutes of critical care services and ID physician B, of the same group, sees the same patient for an additional 40 minutes of critical care services. The total time reported by the billing unit should be 70 minutes, and the group should be reimbursed for that amount.

For patients and services that do not meet the definition for critical care, even if they are in the critical care departmentintensive care unit (ICU) or critical care unit (CCU)report the appropriate evaluation and management (E/M) service codes, Trew explains. For example, she says, for emergency department services, use 99281-99285; for initial inpatient services, use 99221-99223; for subsequent inpatient services, use [...]

- Published on 2000-07-01