Improve Utilization of Critical Care Codes to Increase Reimbursement for Emergency Services
Published on Fri Jan 01, 1999
Many ED groups may be missing out on a significant amount of revenue because they are underusing the evaluation and management codes for critical care services (99291-99292).
When I talk to physicians, I ask them to estimate what percent of the care they provide is critical care, and, typically, they say 5-10 percent. But, when you look at the billing companies that specialize in emergency medicine, they usually only bill critical care about one percent of the time, observes Betty Ann Price, RN, BSN, CCS-P, president of Professional Reimbursement Strategies, a practice management and reimbursement consulting firm based in Palmetto, FL.
CPT defines critical care services as the evaluation and management of the unstable critically ill or unstable critically injured patient, requiring the constant attendance of the physician.
Treating victims of motor vehicle accidents with multiple traumatic injuries, and the management of chest pain patients who present with unstable vital signs are just two examples of care that is often provided in the emergency department which could most likely be coded as critical care services. But, because these codes are specifically based on time, which is difficult to document in the ED, most departments end up billing critical care services with the emergency department services codes (99281-99285), which are not time-specific or as profitable.
A level five E/M code for emergency services (99285) carries only 4.24 relative value units (RVUs), while critical care code 99291 is worth 5.60 RVUs, Price adds.
The key to getting adequate reimbursement for critical care, she explains, is in knowing when and how to bill for it. Providing accurate documentation that the physician performed these services, and making sure that your third-party payers recognize that this is significant portion of emergency care provided to their members, is critical.
What Is Critical Care?
Billing for critical care services is a tricky area for emergency medicine because exactly what constitutes a critical illness, injury or complication is not clearly defined in CPT, says John Turner, MD, PhD, director of documentation and coding compliance at Team Health, an emergency medicine practice group based in Knoxville, TN.
Although CPT states critical care codes should be used for the care of an unstable patient who requires the constant attendance of the physician, what is the definition of unstable?
Some patients have vital signs that are outside the norm for most people, but are normal for them. Sometimes patients may present with a seemingly minor problem, but then later require life-saving treatment.
How are ED coders supposed to know that the care provided meets the medical standard of critical care?
Turner advises his coders to first rely on the physicians notes in the patient chart.
1. Critical care is the subjective judgment of the physician. Did the physician write critical care services provided [...]
