ED Coding and Reimbursement Alert

Know how to count critical care minutes.

Proper documentation and coding of critical care services are essential components of the ED billing process and have been covered in this publication many times. Clear and accurate documentation ensures that the emergency physician receives appropriate reimbursement for the complex and time-intensive care they provide to critically ill or injured patients.

Professional coders who specialize in emergency medicine are well-versed in the criteria that must be met when reporting CPT^® 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)). Critical care services are provided to a patient when there is a high probability of imminent or life-threatening deterioration in the patient’s condition; the care involves high-complexity medical decision making (MDM) to treat vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.

Document Critical Care Time Correctly

For the period of time reported as critical care services, the physician must devote their full attention to the patient. The ED physician’s documentation must indicate that care was provided for a minimum duration of 30 minutes to report critical code 99291.

In terms of documentation, the totality of the medical record should describe the patient’s condition, the interventions and treatments provided, the time spent providing critical care, and the physician’s involvement in the patient’s care. This documentation should support the medical necessity of the critical care services.

Coding for critical care cases is generally straightforward for experienced ED coders. Typically, a critically ill or injured patient arrives at the ED, and the physician provides critical care, documenting their total attention time. This documented time is used to report 99291. If the documented time exceeds the initial time frame covered by 99291, additional time is reported using CPT^® code +99292.

However, there are situations that can present challenges in accurately assigning the appropriate critical care codes. These include critical care provided to discharged patients, critical care along with another evaluation and management (E/M) service on the same day, critical care extending past midnight, and critical care delivered by multiple physicians. These scenarios require careful consideration to ensure accurate coding.

Critical Care for a Discharged Patient

In some cases, patients who initially qualify as critical care may be discharged from the ED. While critical care is typically associated with intensive medical interventions and hospital admission, there are instances where the severity of the patient’s condition is resolved or rapidly improves due to the critical interventions provided by the physician during their ED visit.

Clinical scenarios for critical patients who are discharged home from the ED may include cases such as overdose, anaphylaxis, angioedema, asthma/respiratory distress, or other issues that can be resolved or rapidly improved with aggressive treatment in the ED. These patients may exhibit signs or symptoms that indicate a high likelihood of imminent or life-threatening deterioration, qualifying for critical care coding based on the severity of their symptoms. These patients can eventually safely be discharged home once their condition stabilizes after treatment in the ED.

The medical record should demonstrate the severity of the patient’s condition at the time of presentation and the interventions performed. Discharging a critical care patient to home is not that common, but certainly happens. Being discharged does not preclude the case from being reported as critical care.

Do This on Same-Day E/M, Critical Care

According to the Centers for Medicare & Medicaid Services (CMS), effective as of Jan. 1, 2022, in cases where a patient receives both an E/M visit and critical care services on the same calendar day, both services may be billed if certain criteria are met. This includes the requirement that the E/M visit was provided prior to the initiation of critical care services at a time when the patient did not require critical care. Additionally, the medical record documentation must support that both services were medically necessary and that they were separate and distinct, with no duplicative elements from the critical care services provided later in the day.

For example, a patient presented with chest pain and underwent a full cardiac workup. The medical record supports billing 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making). However, while awaiting an inpatient bed, the patient developed hypotension and ventricular

tachycardia, necessitating 45 minutes of critical care provided by the ED physician.

Based on the CPT^® and CMS guidelines, it is appropriate to bill for both the E/M visit and the critical care services, given that the criteria outlined above are met. It is crucial to ensure that the medical record documentation clearly demonstrates that the E/M visit was provided prior to the initiation of critical care, and that the services provided were medically necessary and distinct from the critical care services later in the day.

Do This on Critical Care That Transcends Midnight

When providing critical care services that extend beyond midnight, it is important to understand the guidelines provided by CPT^® and CMS for critical care that continues after the clock strikes midnight.

According to CPT^® and CMS, when continuous critical care spans the transition of two calendar dates, it is considered a single service and should be reported with the calendar date on which the service began. Crossing midnight does not reset the clock and create a new first hour. Therefore, if critical care is initiated and performed continuously from 11:25 p.m. on Monday until 12:35 a.m. on Tuesday, it should be reported as a single instance of critical care with Monday as the date of service.

It is important to recognize that any interruption in the continuous provision of care constitutes a new episode of service. For example, if the above patient’s condition has stabilized in the ED but deteriorates while awaiting an inpatient bed, leading to the need for critical care to be reinitiated at 2:50 a.m. on Tuesday, this represents a separate instance of critical care. Consequently, the time spent providing critical care from 2:50 a.m. onwards will be reported separately, with Tuesday as the date of service.

Do This on Critical Care by Multiple Physicians

In the scenario where an ED physician initially provides critical care services and reports CPT^® code 99291, any additional ED physicians within the same group who subsequently provide care to the same patient on the same date should use +99292 to report the additional time intervals. It is important to note that CPT^® code 99291 should not be reported more than once for the same patient on the same date by more than one physician within a group.

If an ED physician provides the initial critical care service but does not meet the required time to report 99291, another ED physician within the same group can continue to deliver critical care to the same patient on the same date. The total time spent by both practitioners is combined to meet the time requirement for billing 99291. Once the cumulative required critical care service time is provided, you can report 99291. Additional critical care time beyond that encompassed in 99291 would be reported with +99292 when an additional 30 minutes of critical care has been provided to the same patient on the same date.

For example, if ED physician Dr. Adams provides 20 minutes of critical care and then hands off care to ED physician Dr. Barnes during shift change and an additional 20 minutes of critical care is provided, the total time spent on critical care is reported as 40 minutes using 99291.

However, if Dr. Adams provides 60 minutes of critical care before handing off to Dr. Barnes, and Dr. Barnes continues to provide an additional 60 minutes of critical care, the coding differs. Dr. Adams would report 99291, while Dr. Barnes would report either +99292 (for Medicare payers, and those that follow Medicare guidelines) or +99292 x2 (for non-Medicare payers).

It is essential for emergency physicians and coders to carefully consider these various scenarios and follow the specific guidelines outlined by CMS and CPT^® to ensure accurate coding and appropriate reimbursement. By ensuring proper documentation and accurate coding, emergency physicians can facilitate optimal care for critically ill or injured patients while maintaining compliance with coding guidelines.

Written by Todd Thomas, CPC, CCS-P, president of ERcoder, Inc. and a member of the ED Coding & Reimbursement Alert editorial advisory board.