EM Coding Alert

If the ‘critical care’ doesn’t last 30 minutes, we’ve got the coding solution.

One of the more challenging — and most profitable — evaluation and management (E/M) services to report is critical care. There are several criteria the visit must meet in order to report critical care, and missing even one of these elements could result in a denial.

On the other hand, not reporting critical care when you rightfully could have swings the pendulum the other way, and you risk leaving deserved cash on the table.

Check out this Q&A with those in the know about the tenets of critical care:

Q1: What does ‘critically ill or injured’ mean’?

A1: “Critically ill or injured implies that there is a risk of loss-of-life or loss-of-function/further loss-of-function of a major organ or organ system, with an acute or exacerbated presentation of the condition,” explains Joshua Tepperberg, CPC, senior coding analyst at caduceus inc., in Jersey City, NJ.

Some examples of potential critical care scenarios include, but are not limited to, patients suffering from:

• respiratory failure,
• cardiac failure,
• kidney failure,
• metabolic failure,
• brain injury,
• major traumas
• or a combination of the above or with other co-morbidities.

Example: A 65-year-old patient reports to the emergency department (ED) via ambulance after an automobile crash. He is in and out of consciousness, and in atrial fibrillation and respiratory distress. Also, the patient has suffered blunt force trauma to the chest. To ensure the patient’s stability, the ED physician provides 60 minutes of critical care, and then sends him to the OR for further treatment.

On the claim, you’d report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the service.

Q2: Where can the physician perform critical care?

A2: Anywhere.

You should forget setting when looking at potential critical care claims; focus on the patient’s condition instead. As long as the patient is critically ill or injured — and getting the patient out of that state takes a minimum of 30 minutes — then you can report critical care. The patient doesn’t have to be in the ED.

Critical care is not about the location of the service; rather it’s focused on the content of the service, explains Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, founder and chairman of Edelberg + Associates in Atlanta. Thus, your physician can provide critical care just about anywhere; “in the ED, up on the [regular inpatient] floors, in the ICU during an observation stay,” continues Edelberg.

Conversely, it’s important to note that a patient in the ICU or ED doesn’t inherently receive critical care. The medical necessity and the documentation to support critical care is what matters when choosing 99291 and 99292.

Q3: What should I do when the critical care lasts less than 30 minutes?

A3: You should choose a code other than 99291. Which E/M code you choose will depend on the setting and the type of E/M service. If the care occurs in the observation unit, you should report the appropriate observation code based on the notes.

For example, let’s say your ED physician spends 22 minutes stabilizing a critically injured patient in cardiac arrest. Notes indicate a level-five ED E/M service. On the claim, report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity) for the service.