ED Coding and Reimbursement Alert

The 30-minute threshold is just one benchmark you must meet before billing these codes.

Although emergency departments typically see critical care patients all year round, many EDs are reporting an uptick in critical care services due to the coronavirus pandemic. Sometimes coding these services can be as simple as adding up the time and circling the right code, but there are other situations when you might find these services challenging to report.

To get to the bottom of coding critical care, we’ve rounded up some of the most common confusing topics on this issue, and we’re sharing advice on how to code these scenarios.

Check This Critical Care Refresher

Although sometimes it seems like every patient who comes into the ED is in critical condition, the reality is that from a CPT^® standpoint, critical care occurs when a physician or other qualified healthcare professional directly provides medical services for a critically ill or critically injured patient. As always, the documentation must support the necessity of the critical care service when you 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)).

To qualify for critical care, a service must meet all of the following requirements:

• The patient must meet the CPT^® definition of critical care which includes “a high probability of imminent danger of deterioration.”
• The physician must perform the critical care services, including using high-complexity decision making to assess, manipulate, and support vital system functions to treat vital organ system failure or to prevent further life-threatening conditions.
• All critical care services must last at least 30 minutes on a given date of service. The time can be continuous or intermittent.

“Critical care is … determined by the nature of the care being delivered and the condition of the patient,” said Jessica Miller, CPC, CPC-P, CGIC, Manager of Professional Coding for Ciox Health in Alpharetta, Georgia in a presentation delivered during AAPC’s HEALTHCON 2020.

Beware Services Bundled Into Critical Care

The CPT^® critical care guidelines include a specific list of services that are bundled into the professional components of critical care that you should not report separately when performed by the physician providing the critical care during the critical care period. The entire list is as follows:

• Interpretation of cardiac output measurements (93561, 93562)
• Pulse oximetry (94760,94761, 94762)
• Blood gases, and collection and interpretation of physiologic data (e.g. ECGs, blood pressures, hematologic data)
• Chest x-rays, professional component (71045, 71046)
• Gastric intubation (43752-43753)
• Temporary transcutaneous pacing (92953)
• Ventilator management (94002-94004, 94660, 94662)
• Vascular access procedures (36000, 36410, 36415, 36591, 36600)

Don’t miss: When your physician provides any of the above services during a critical care session, you should not report them separately. However, facilities can report these services separately.

Mind Time for Critical Care

Time is a vital component of the critical care codes. The physician should always record the time spent with the patient in the medical documentation.

“The documentation must include the total time the physician spent in critical care for/with the patient,” emphasizes Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. “It does not have to be continuous, but it does have to be the total time on one full calendar day. Without this, the coding team would never know how long Dr. X spent with the patient.”

You should report 99291 for the first 30-74 minutes of critical care on a given date. Bill this code only once per date even if the time the physician spends is not continuous on that date. You should report critical care of less than 30 minutes total duration on a given date with the appropriate E/M code, not a critical care code.

Then, you should report +99292 for additional block(s) of time of up to 30 minutes each beyond the first 74 minutes.

“The time that can be reported as critical care is the time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit,” according to the CPT^® guidelines.

You can report critical care: The physician can report the time they spend on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff, or documenting critical care services in the medical record as critical care, even though these services did not occur at the patient’s bedside.

Also, “when the patient is unable or lacks capacity to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient,” per the guidelines.

Don’t report critical care: However, any time the physician spends in activities outside of the unit or floor, such as telephone calls they take at home, in their office, or somewhere else in the hospital, would not count as critical care because the physician is not immediately available to the patient in these circumstances.

Additionally, if the physician spends time on activities that do not directly contribute to the patient’s treatment, such as administrative meetings, they cannot report these services as critical care, even if they perform these activities in the critical care unit, according to the guidelines.

Don’t Count on ROS, HPI

Keep in mind that you won’t need to calculate which levels of review of systems (ROS) and history of present illness (HPI) you must meet before you can report 99291. These elements aren’t necessary in determining whether critical care is warranted, according to CPT^® guidelines.

Critical care is not based on any of the data elements associated with emergency department E/M levels. It’s based on time only.

Because critical care is a time-based code, you are excused from meeting all the usual elements with regard to HPI; physical examination (PE); past, family, and social history (PFSH); and ROS that are required for the standard ED evaluation and management codes 99281-99285. However, the chart must reflect the nature of the patient’s critical illness and that at least 30 minutes of care was spent outside of separately billable procedures.

In Some Cases, Discharge Can Occur Post-CC Service

Not every critical care encounter will result in a hospital admission, which can be confusing for coders. For instance, suppose you treat a patient who was in the ED for anaphylaxis so severe that the physician performed critical care services on them. However, the patient was discharged from the ED that same day. Assuming the documentation supports the service, you can still report a critical care code. Just because patients require critical care services doesn’t mean they won’t improve enough to warrant discharge — in the case of an anaphylactic reaction due to allergies, it would be possible for the stabilized patient to be discharged directly from the ED.

As long as the physician’s work meets the definition of critical care, there is no requirement that they admit the patient to the hospital to report codes 99291 or +99292.

Common clinical scenarios for critical patients who are discharged include anaphylaxis, angioedema, asthma, and sometimes even congestive heart failure. These are just examples, however — you should not consider a service critical care based on the diagnosis. Whether a service meets critical care requirements depends on the treatment, the level of care performed, the gravity of the patient’s condition, and the physician’s documentation and notes.

Remember the exceptions: “You should not consider that the provision of care to a critically ill patient is automatically a critical care service just because the patient is critically ill or injured,” CMS says in MLN Matters article MM5993. “To this point, each physician providing critical care services to a patient during the critical care episode of an illness or injury must be managing one or more of the critical illness(es) or injury(ies) in whole, or in part.”

In other words, if the patient presents with anaphylactic shock and the ED physician administers an epinephrine shot but a cardiologist or other specialist manages the patient’s Coumadin dosing, then it’s likely that the ED physician’s notes would support reporting critical care and the cardiologist’s might not. This is why it’s essential to read the entire medical record before selecting a code.