ED Coding and Reimbursement Alert

Carefully documented time and resources spent is the key to accurate facility coding

Identifying and reporting the hospital component of ED critical care presents a challenge for hospitals as the rules differ enough from the professional rules to create a significant challenge. This is especially true when the hospital's trauma team is activated to deal with a critical injury presentation.

As of January 1, 2007, critical care services were paid at two levels, depending on whether or not there was also activation of the hospital's trauma team. Hospitals will receive one payment rate for critical care without trauma activation and will receive additional payment when critical care is associated with trauma activation.

When critical care services are provided without trauma activation, the hospital may bill CPT® code 99291, (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). If additional critical care time is documented over 74 minutes, 99292 (...each additional 30 minutes [List separately in addition to code for primary services]) would be billed for each additional 30 minutes of critical care, says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates in Baton Rouge, LA.

If trauma activation occurs under the circumstances described by the National Uniform Billing Committee (NUBC) guidelines that would permit reporting a charge, the hospital may also bill one unit of code Trauma Activation code G0390, which describes trauma activation associated with hospital critical care services.

Tip: Time, intensity and content of the service form the foundation of this E/M service.

Critical care is defined as a critical illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition.

The key to understanding appropriate billing of critical care in the ED is an understanding of how a routine E/M service makes the jump to critical care. As the CPT® guidelines indicate, hospitals that provide less than 30 minutes of critical care should bill for a visit, typically an emergency department visit, at a level consistent with their own internal guidelines, says Edelberg. Critical care requires decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to, central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure, she adds.

Count Time as Your Critical Factor

The time spent managing the critical patient is crucial to assigning the correct code. For the hospital to bill the facility component of this service, documentation must support a minimum of 30 minutes of critical care service to the patient.

Medicare PUB 100-94 MCP, Transmittal 1139, Dec 22, 2006 stated this 30 minute minimum has always applied under the OPPS and will continue to apply, says Edelberg. CMS says that under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or injured patient, she adds.

If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once. Thus, to assure you can code this service correctly, documentation must clearly state that the 30 minute threshold has been met. It is important to include start and stop times spent with the patient by each health care provider so that coding professionals can accurately count individual and group provider times while preventing overlap of critical care time claimed when more than one provider is at the bedside, Edelberg explains.

Don't Forget Any Separately Identifiable Procedures

Critical care includes certain other separately identifiable procedures or services that cannot be billed separately; such as interpretation of cardiac output measurements, chest X-rays, pulse oximetry, blood gasses, information data stored in computers, gastric intubation, temporary transcutaneous pacing, ventilator management and vascular access procedures. (CPT® provides the codes related to each of these bundles services.)

Additional procedures provided during the visit are identified separately and paid separately within the CPT® and CCI (Correct Coding Initiatives) rules for separate procedures, warns Edelberg.

Often, critical patients require life-saving interventions in the emergency department. One of the most frequent is CPR. The levels of critical care are determined by time; when CPT® code 92950 is reported, the time required to perform CPR is not included in critical care. Additional procedures provided by ED staff or consultants supported by ED staff are separately billable by the hospital in addition to critical care as long as the time spent performing these procedures is removed from the time used to determine critical care, says Edelberg.