ED Coding and Reimbursement Alert

And watch your reimbursement rise from the ashes

If your payment for critical care services leaves something to be desired, your practice may be inaccurately reporting these services based on correctable misconceptions. Take stock of these common 99291-99292 pitfalls to make sure you-re not falling prey to critical care no-no-s. Myth #1: Since critical care is the highest level of E/M, you need to satisfy all the E/M elements. Reality: Actually, 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]) are time-based codes--and if you look carefully at the code descriptor requirements in CPT, you-ll find no specific requirements for history, physical exam and medical decision-making (MDM).

-Most of the codes in the E/M section of CPT have specific key element requirements with regard to history, physical exam, and medical decision-making,- says Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI, an ED billing company in Stoneham, Mass.

For example, to report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history, a comprehensive examination, and medical decision- making of high complexity), you need a comprehensive history, comprehensive physical exam, and high-level MDM--but those requirements aren't present for critical care, Granovsky says. -These are time-based codes that also require a high probability of imminent or life-threatening deterioration in the patient's condition.-

And that time must include at least 30 minutes of care, excluding any separately billable procedures the physician performs, such as endotracheal intubation. Myth #2: Critical care must take place in the CCU or ICU. Reality: While physicians usually end up treating critical care patients in the designated critical care unit (CCU) or intensive care unit (ICU), critical care can take place anywhere in the hospital, says Valrie Hall, CCS, with Peak Health Solutions. According to CPT, critical care isn't specific to any location, such as an ICU or CCU. What determines whether you can report 99291 is the patient's critical condition, Hall says.

If necessary, the physician can perform critical care on the medical-surgical floor, in an observation unit, and particularly in the emergency department, Granovsky says.

For example, the ED physician is working a clinical shift and responds to a code blue called by the radiology department. An inpatient was receiving an x-ray study, had a perforated ulcer, and went into cardiac arrest. The ED physician intubates the patient and restores her vital signs, starts her on dopamine and fluids, and gives her needed blood, all in the radiology suite. [...]