Are You Underplaying the Critical Care Codes?
Published on Sun Dec 01, 2002
You don't need a medical disaster to report codes for critical care in the emergency department. If you're overly cautious about assigning them, you're losing out on a key resource for ED reimbursement. Code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) is the "most underreported code in the ED," says James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa. Most emergency departments reserve 99291 and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) for only the most life-threatening and difficult medical scenarios. Too often, coders report a code from the 9928x series, rather than a critical care code even when the critical care code would bring more reimbursement.
Usually, insufficient physician documentation not your coding skills causes the scarcity of critical code claims. "So often, physicians 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 Daytona, Fla. If you don't have physician documentation, you can't use a series of codes whose determination relies heavily on it, McFarland says. Only with sufficient documentation can your physician avoid noncompliance and increase reimbursement for his work. It's your task as a coder to educate your physicians about the payment opportunity they sacrifice if they don't properly understand and document critical care, Blakeman says. Tell them that the ED should, as he suggests, "stop paying for little stuff and charge appropriately for bigger stuff." Here's how: What Qualifies As 'Time Spent' According to CPT guidelines, critical care codes report the time physicians spend when "directly" working on the care of a critical patient.
Tell your physicians to subtract the time spent on procedures from their critical care time. Critical care time does not include time spent on separately billable procedures and services.
Apply critical care codes for evaluation and management services when: the physician directly delivers medical care for a "critically ill" or "critically injured" patient
the patient has a "high probability of imminent or life-threatening deterioration"
the physician documents high-complexity decision-making. Critical care does not include the time spent on:
activities that occur outside of the ED or on the floor, including telephone calls taken anywhere
activities that don't directly contribute to the patient's care, including meetings, and time spent consoling the family (unless that conversation brings up points relevant to patient history, Blakeman says)
performing separately reportable procedures or services. Critical care codes require that a patient have the immediate potential to become unstable, meaning the patient doesn't have to already be unstable to require critical care.
Here's an [...]
