ED Coding and Reimbursement Alert

Organ system impairment often indicates 99291 service

If coders recognize critical care indicators, and doctors diligently document encounter specifics, you can capture critical care each time a physician provides it in the ED.

Critical care is a fairly frequent service in most EDs, but your ED might not be reporting 99291 and 99292 as often as it should.

"Critical care is commonly performed but underreported," says Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla. "This service is what emergency medicine is all about. Unfortunately, I believe many EDs often miss critical care coding opportunities."

Why? Coders often fail to recognize terms that may indicate critical care. Plus, many physicians provide critical care but fail to document it thoroughly enough, leaving the coder without enough evidence to support 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

Check for High MDM on Critical Care Encounters

Edelberg recommends that coders get familiar with the CPT definition of critical care if they are not already. For a patient to qualify for critical care, the encounter must meet the following three parameters:

A patient requiring critical care has a condition that acutely impairs one or more vital organ systems. "A description of the condition must be in the documentation," Edelberg said during her recent Coding Institute audioconference "Chart Review Must-Haves for ED Coding" (http://www.audioeducator.com).

Examples of conditions that could acutely impair a vital organ system include:

- central nervous system failure

- circulatory failure

- shock

- renal, hepatic, metabolic or respiratory failure.

Critical care patients must have a high probability of imminent, life-threatening deterioration if the physician does not address the condition. " -High probability- doesn't mean the patient is deteriorating right now -- it means he could deteriorate if the physician does not treat him right away," Edelberg said.

The physician must perform high-complexity medical decision-making (MDM) to report 99291. During this MDM, the physician must assess the patient's deterioration potential, perform services to prevent deterioration and provide support if the patient's condition worsens.

3 Principles Are Required

The key to identifying critical care correctly is ensuring the physician provides the high level of assessment, manipulation and support -- three key principles -- to treat/prevent further life-threatening deterioration. "This assumes that some level of life-threatening deterioration has already occurred, which requires physician intervention to assess the risk and complexity, manipulate to prevent further risk, and provide support through management," Edelberg said.

Whenever encounter notes satisfy these requirements, be on the lookout for a 99291 possibility -- though you-ll still need to meet time parameters before qualifying for critical care.

Example: A COPD patient presents to the ED complaining of dyspnea and exhibiting altered mental status with a respiratory rate of 36 and a pulse ox of 89 percent. The ED physician decides the patient needs high-flow oxygen, and he orders continuous nebulizer treatments and continuous positive airway pressure (CPAP). He lists acute respiratory failure (518.81) as a differential diagnosis in the record, and includes a time statement indicating he spent 43 minutes providing critical care for this patient net of the time spent performing separately billable procedures.

This is a likely critical care scenario, according to Edelberg -- if the physician includes the proper documentation.