ED Coding and Reimbursement Alert

Every minute counts in preventing costly 99291 denials

The trick to securing reimbursement for critical care services is correct documentation of the physician's time - often a tall order in a busy emergency department - and the patient's condition. Here's what you need to see in the chart to report critical care.

Separate 2 Key Components for Time Spent

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) are time-dependent, which means you'll need to know exactly how much time the physician spent performing critical care services. This time doesn't all need to be at the patient's bedside, says Barbara Cole, BSN, RN, CPC, president of ProTech Reimbursement Services, a national firm specializing in emergency medicine professional and technical coding in Collegeville, Pa.

According to CPT, "When the patient is unable to participate in discussions - or clinically incompetent - you can report time the physician spent on the floor or unit with the patient's family members obtaining a medical history, reviewing the patient's condition or prognosis, or discussing treatment options as critical care services, provided that the conversation bears directly on the management of the patient."

Don't miss: When you're evaluating the physician's time spent with critical care, it's just as important to know how much time the doctor didn't spend in critical care of the patient. If the physician is spending time performing separately billable procedures, don't include that time in the minutes you bill for critical care.

Include - or Exclude - Other Procedures

CPT bundles certain procedures into the time the physician spends on critical care, but others are separately billable. You can earn separate reimbursement for these procedures: cardiopulmonary resuscitation, endotracheal intubation, initial pericardiocentesis, central venous catheter placement, chest tube, and EKG interpretations. Other procedures performed during critical care, however, are included in 99291 and 99292: cardiac output measurements, chest x-rays, pulse oximetry, blood gases, gastric intubation, and temporary transcutaneous pacing.

You have to make sure the physician documents all the services he performed, says Sandra Soerries, CPC, CPC-H, a healthcare reimbursement consultant at RSM McGladrey in Kansas City, Mo.

Smart idea: "To prevent loss of reimbursement, use a charge ticket to assist physicians in capturing all charges - to make sure they mark down everything they do," Soerries says. "Even if the services are critical care, they should mark them anyway, because we know while some of them are bundled, others might not be."

Patient Needed Physician 5 Minutes Ago

To bill for critical care services, the patient's condition must be such that he needs the physician's full and immediate attention. Typical critical care patients include patients with large strokes, severely altered mental status, seizures, shock, respiratory or cardiac failure, or sepsis. Based on the current definition of critical care, additional patient presentations that may qualify for critical care include severe allergic reactions, severe asthma, and active chest pain with EKG changes.

Tip: Stable vital signs are unlikely in these scenarios, but don't rule out critical care codes just because a patient has stable vital signs, Cole says.

According to CPT, if illnesses or injuries are "critical," they "acutely impair one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the condition" without the assistance of a physician. Because of the severity of their conditions, these patients usually require multiple diagnostics, Cole says.

Ask Yourself 5 Questions

If you're debating whether to report critical care codes, Cole recommends answering these questions to help you tip the scales to one side or the other: