Cardiology Coding Alert

There's more to 99291-99292 than just what happens in the ICU

Discover two major pitfalls you should avoid to ensure your practice receives the critical care payment it deserves.

Define Critical Care

Before you use critical care codes 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]), you should review how CPT defines a critical care patient.

According to CPT, the patient must have "a critical illness or injury [that] acutely impairs one or more vital organ systems" and requires the cardiologist to 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."

Why is this important? Your claim has to show that the cardiologist's services were reasonable and medically necessary. If they aren't and do not meet the criteria for critical care services, then you'll have to recode this as another appropriate E/M service (such as subsequent hospital care codes, 99231-99233 or inpatient consultation codes, 99251-99255), depending on the level of service the cardiologist provided, says Erin Forbes, medical billing specialist at Inlet Cardiopulmonary and Associates in Pawleys Island, S.C.

Pitfall 1: If your cardiologist provides care to a critically ill patient, you shouldn't automatically assume you should code his services using critical care codes (99291-99292). For example, if a cardiologist makes rounds in an intensive care unit (ICU), you shouldn't assume this is critical care because you're unlikely to meet the time requirements for critical care.

Remember to Specify Time

When you're reporting critical care, make sure your cardiologist documents the time spent with the patient. These E/M codes are time-based. Keep in mind: Time that your cardiologist spends performing separately reportable procedures does not count as critical care.

Heads up: Your cardiologist has to provide his or her "full attention" to the patient, but that doesn't mean that critical care time only includes the time the cardiologist spends at the patient's bedside. Time spent at the nursing station, on the floor reviewing test results or imaging studies, discussing the critically ill patient's condition with other medical staff or family, and documenting critical care services all qualify as critical care, Forbes says.

This is how to break down the codes according to time:

Code                       Time  
Other E/M code        Less than 30 minutes 
99291                      First 30-74 minutes 
+99292                    Each additional 30 minutes
 
Pitfall 2: Critical care does not have to be continuous, but you should make sure your cardiologist records the time he or she spends with the patient in the patient's chart and explains everything he or she did, Forbes stresses. Documentation reading "critical care > 30 minutes," for example, is generally too vague. Keep in mind: "However, in the absence of specific start and stop times, a general statement establishing the total amount of time spent in critical care is better than nothing," says Jim Collins, ACS-CA, CHCC, CPC, CEO of the Cardiology Coalition in Mathews, N.C.