Cardiology Coding Alert

Remember the EKG rule when counting critical care time.

Cardiologists may offer critical care in a variety of scenarios. But because the critical care codes are unlike the other E/M codes that you report every day, you may be hesitant to take the risk of reporting critical care. Check out these tips on what “critical” actually means and which services are, and are not, bundled into the critical care codes so you can code with confidence.

Insurers May Not Agree Patient Was Critically Ill or Injured 

Whether the patient was critically ill or injured is perhaps the most important question you’ll need to answer on any critical care claim. You must be able to establish that the patient is critically ill or injured to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (… each additional 30 minutes [List separately in addition to code for primary service]), reports Michael A. Granovsky, MD, FACEP, CPC, President of Logixhealth, a national emergency department coding and billing company based in Bedford, Mass.

CPT® defines critically ill or injured as “an injury or illness that acutely impairs one or more vital organ systems such that there is high probability of imminent or life threatening deterioration in the patient’s condition,” Granovsky explains. 

In addition, minimal time thresholds of care, at least 30 minutes, must be clear from the medical records, says Granovsky.

He offers these examples of patients that insurers would consider critically ill or injured: unstable vital signs, severe hypernatremia, which is a high blood sodium level, severe dyspnea, or a hypertensive crisis. Appendix C of the CPT® manual offers various other possible examples, such as a patient with a history of myocardial infarction presenting with sustained ventricular tachycardia. But you must keep in mind that these are examples, and you should always code based on the patient’s specific case and the physician’s judgment of that case. The advice below may help make that decision clearer.

Payers May Question ‘High Probability’ 

Although most critical patients will be actively critically ill or injured, some may just be unstable to the point that they will very likely become so without immediate treatment. 

When determining whether or not a patient is critically ill or injured, the physician should consider the likelihood that the patient would have a clinically significant deterioration if nothing was done in the next hour. If the probability for imminent or life threatening deterioration is high, critical care may be an appropriate consideration.  

Where Can the Physician Provide Critical Care?

Place of service for critical care is not restricted in CPT® other than to identify typical areas of a facility where it may occur. While most critical care will occur in a critical care area (ICU, ED, etc.), the physician can provide 99291 services in any place of service the patient requiring it presents. According to the Medicare database, about 25 percent of all critical care services were provided in the emergency department setting, Granovsky says.

Don’t Forget the Services Bundled into 99291 and +99292

The CPT® critical care preamble includes a specific list of services bundled in to code 99291 that you should not be report separately. These include:

• The interpretation of cardiac output measurements (93561, 93562)
• Pulse oximetry (94760, 94761, 94762)
• Chest X-rays, professional component (71010, 71015, 71020)
• Blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data (99090)
• Gastric intubation (43752, 43753)
• Transcutaneous pacing (92953)
• Ventilator management (94002-94004, 94660, 94662)
• Peripheral vascular access procedures (36000, 36410, 36415, 36591, 36600).

Bottom line: When your physician provides any of the above services during a critical care session, do not report them separately.

Non-bundles: You can report the below services separately from 99291 and +99292, as CPT® does not bundle them into critical care:

• CPR (92950)
• Endotracheal intubation (31500)
• Tube thoracostomy (32551)
• EKG interpretations (93010, 93042)
• Central venous catheter placement (36555, 36556).

Consider this example: A patient presents with worsening shortness of breath. The physician examines the patient and finds him to have elevated blood pressure and tachycardia. The patient receives a Cardizem drip to control his heart rate. The physician orders labs, chest X-ray, and an EKG, and performs multiple re-evaluations. The physician interprets both the X-ray and EKG and diagnoses the patient with congestive heart failure (CHF) and atrial fibrillation. The EKG interpretation takes the physician four minutes, and the rest of the encounter took 46 minutes.

In this example, the physician spent 46 minutes providing critical care services to this patient (this time excludes time spent interpreting the EKG). On the claim you would report the following:

• 99291 for the 46 minutes of critical care
• 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for the EKG
• ICD-9 codes 786.05 (Shortness of breath), 428.0 (Congestive heart failure, unspecified), and 427.31 (Atrial fibrillation) linked to 99291 and 93010 to prove medical necessity for the services (for ICD-10, you would report R06.02, Shortness of breath; I50.9, Heart failure, unspecified; I48.91, Unspecified atrial fibrillation).

On this claim, you would not code the chest X-ray interpretation, as it is included in the critical care code, says Granovsky.

Of note: Be sure to deduct the time spent providing these separately billable procedures (such as the EKG) from your critical care time reported, warns Granovsky.

Is It 30 or 31 Minutes to Qualify For Critical Care?

In the case of code 99291, there is specific language in CPT® that states 30 minutes both in the code descriptor itself and in the time threshold chart in the critical care section preamble. So for 99291, CPT® describes a threshold of at least 30 minutes, Granovsky explains.