EM Coding Alert

Can you get all the codes right on these 2 cases?

Deciphering encounter notes to find out if, and why, critical care occurred is the key to successful claims. Test your coding knowledge by trying to code these case studies correctly, right down to the ICD-10 codes.

(Cases come courtesy of Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Mich.)

Case 1

The physician is called to the postoperative recovery area because a patient is in atrial fibrillation six hours after a gall bladder removal surgery. The patient has developed an abscess and is also in septic shock.

During the encounter, the physician is either at the patient’s bedside, or at the nurse’s station to administer medication to stop the irregular heartbeat and monitor the patient. The physician is watching for signs that the heartbeat has returned to normal, and the patient is out of danger. The physician is also watching for signs of toxicity related to the medication, to be sure the patient does not develop additional symptoms or get worse. Notes indicate that the physician spent 38 minutes providing these services.

Case 1 Coding

Since the notes indicate that the physician spent only 38 of the 104 documented minutes within the encounter exclusively stabilizing this critically ill patient, it is critical care. You should report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care time, and include the following diagnoses in this order to fully depict the patient’s critical condition:

• I48.91, Unspecified atrial fibrillation
• T81.4, Infection following a procedure
• T81.12, Postprocedural septic shock
• L02.91, Cutaneous abscess, unspecified
• K82.9, Disease of gallbladder, unspecified.

Case 2

A patient reports to the emergency department (ED) in respiratory distress. He is a three-packs-a-day smoker with a diagnosis of chronic obstructive pulmonary disease (COPD). The physician administers breathing treatments and is monitoring the patient’s oxygen saturation and blood gases. During the entire encounter, the physician is either at the patient’s bedside or at the nurse’s station monitoring the patient for respiratory or cardiac arrest. Total encounter time is 104 minutes.

Case 2 coding

Since the notes indicate that the physician spent all 104 documented minutes of the encounter exclusively stabilizing this critically ill patient, the whole period of time is considered critical care. You should report 99291 and 99292 (… each additional 30 minutes [List separately in addition to code for primary service]) for the critical care, and include the following diagnoses in this order to fully depict the patient’s critical condition:

• J80, Acute respiratory distress syndrome
• J44.1, Chronic obstructive pulmonary disease with (acute) exacerbation
• F17.210, Nicotine dependence, cigarettes, uncomplicated.

Remember: As critical care time increases, so would the quantity of 99292 units that you can report. For every 30 minutes after the first 74 minutes of critical care, you can report another unit of 99292. The quantity billed field should indicate how many 30-minute segments the provider performed and documented.