ED Coding and Reimbursement Alert

CPT 2001 has broadened the definition of 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]). The revised introduction to critical care now reads, A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patients condition. The new definition adds high probability to the CPT 2000 language (which itself had been altered to eliminate a prior requirement that the patient be unstable). ED physicians unaware of the change may hesitate to code for critical care and instead rely on 99285 (emergency department visit for the evaluation and management of a patient ) but this can lead to undercoding and lost reimbursement.

Thoroughly Document Time

To bill 99291 instead of 99285, the physician must document a minimum of 30 minutes spent providing critical care. Time involved performing separately billable procedures should not be counted toward critical care time, stresses Roger P. Holland MD, PhD, FAAFP, physician reimbursement specialist and president of Utilization PRO Inc. Physician progress notes must document the total time involved providing critical care services. If time is not legibly and unequivocally documented, the claim will be subject to recoding or denial.

Time counted toward critical care does not have to be continuous, advises David McKenzie, director of reimbursement, American College of Emergency Physicians in Irving, Texas. According to CPT, Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient provided that the patients condition continues to require the level of physician attention defined as critical care.

Avoid Unbundling of Included Services

Some payers (e.g., Medicare) may not reimburse critical care services on the same day as a procedure with a global surgical period unless billed with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to indicate that the service was above and beyond the usual pre- and postoperative care associated with the procedure. According to CPT, the following services are included in reporting critical care when performed during the critical period by the physicians(s) providing critical care.

Chest x-rays (71010, 71015, 71020)

Blood gases (82273)

Interpretation of cardiac output measurements (93561, 93562)

Information data stored in computers (e.g., electro-cardiographs [EKG], blood pressures, hematologic data [99090])

Gastric intubation (91105)

Pulse oximetry (94760 and 94762)

Transcutaneous pacing (92953)

Ventilator management (94656, 94657, 94660 and 94662)

Vascular access procedures (36000, 36410 and 36600)

Any services performed which are not [...]