Identify Critical Care and Receive Vital Payment Boost
Published on Thu Oct 23, 2003
Most emergency department (ED) coders are familiar with the standard scenarios in which critical care is provided: a severely injured accident victim or a patient with unstable vital signs and chest pains. But to maximize your reimbursement potential, you have to know when you can use critical care codes in some lesser-known situations, and what the physician must document before you can report critical care.
Many emergency care coders inadvertently come up short when coding for critical care services (99291 and 99292). The reason? Insufficient documentation. Keeping exact track of time and resources expended - often very difficult in your standard ED - is essential to correct critical care claims, says Caral Edelberg, CPC, CCS-P, president, chief executive officer and founder of Medical Management Resources, a TeamHealth Company.
"We see cases that could be critical care yet can't be billed, because the time is missed or the documentation just isn't enough to support the selection of the critical care code," she says.
So the question becomes: How can ED coders be ethically paid for critical care services without wrapping themselves up in red tape or raising the eyebrows of suspicious payers? A little knowledge will go a long way toward helping your office assess critical care services and obtain payment when they are provided. Think You Can Identify Critical Care? Think Again The first step to correctly reporting 99291 and 99292 is to identify patients who are "critically ill" or "critically injured." According to CPT 2003, "critical" illnesses and injuries are defined as conditions that "acutely impair one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition."
CPT goes on to report that "Critical care involves high-complexity decision-making to assess, manipulate and support vital system functions, to treat single or multiple vital organ system failures and/or to prevent further life-threatening deterioration." In other words, a critical care situation involves a physician with the highest level of preparedness intervening urgently to stop a patient's condition from becoming far worse.
As previously noted, time is also a factor in critical care coding. A minimum of 30 minutes must be spent administering critical care services for a visit to be considered critical care; separately billable procedures may not be included in the time calculation. The physician must also attend exclusively to that patient during documented time for a service to qualify.
For example, a patient who presented with chest pain is undergoing evaluation when she suddenly collapses. The ED physician quickly orders CPR and intubates. After the patient is resuscitated and stabilized, the physician checks her medical history and obtains additional information through conversation with the patient's husband. A chest x-ray is then reviewed for tube [...]
