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Gastroenterology Coding Alert

Don't Fret Over Setting When Coding Critical Care

Published on Wed Apr 06, 2005

Focus your attention on time, documentation requirements

A gastroenterologist can provide critical care just about anywhere he meets the patient and provides the service. If you meet two important requirements in the time and documentation departments, your claim will be successful even if the physician is not in the emergency department or other "critical care area."
 
A patient who receives critical care "does not actually have to be in a critical care setting," says Janeane Long, RMC, of Gastroenterology-Hepatology Associates in Reading, Penn.
 
Bottom line: Keep good records, and most payers will reimburse for 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]).
 
Read on for some expert advice on critical care documentation and time requirements.

GI Bleeding Often Leads to Critical Care

To illustrate proper critical care coding, consider this example: The gastroenterologist treats a patient with macronodular cirrhosis of the liver for severe gastrointestinal bleeding. The patient is hemorrhaging heavily, and the physician needs several minutes to find the bleeding's origin and stop it.
 
The gastroenterologist provides 47 minutes of critical care, during which time he:
 

  •  lavages blood from the patient
     
  •  conducts tests and analyzes results
     
  •  consults with other physicians.

    On your claim, you should:

  •  report 99291 for the critical care services.
     
  •  attach ICD-codes 578.9 (Hemorrhage of gastrointestinal tract, unspecified) and 571.5 (Cirrhosis of liver without mention of alcohol) to 99291 to show the payer why critical care was medically necessary.

    What's the setting? No matter the setting, critical care "is based on time only, for the critically ill or critically injured patient, meaning there is a high probability of imminent or life-threatening deterioration of the patient's condition," says Sharon Clement, CPC, business manager at Norwalk Hospital in Norwalk, Conn.
     
    While most critical care occurs in an emergency department or other "critical care area," Medicare pays for critical care provided in any location if you meet the guidelines. Conversely, a patient's presence in an intensive or critical care unit doesn't necessarily qualify as a critical care situation.

    Advice: Keep Good Time Records
     
    While the above scenario may have occurred in a non-traditional setting, the service is still a viable critical care claim - as long as you meet documentation requirements, experts say.
     
    "Whether a service meets critical care requirements depends on treatment, level of care performed, gravity of the patient's condition, and the physician's documentation and notes," says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City. In critical care, setting is secondary to documentation.
      
    Heed this advice: To lock up reimbursement for your critical care claims, Long offers this short list of tips
    on documentation:
     
    Note a start and stop time for the critical care services. "And also document time spent on all care management services provided in that time," Long says. If the gastroenterologist provided critical care and another service in the same session, be sure to explain how much time the physician spent providing each service.
     
    Give details about all the services the physician provides. "These services would include the usual evaluation and management components," Long says. Other services that may (or may not) be part of a carrier's critical care package include:
     

  •  interpretation of cardiac output studies
     
  •  chest x-rays
     
  •  blood gases
     
  •  ECG
     
  •  blood pressures
     
  •  hematological testing
     
  •  gastric intubations.

    Check with CMS. If you want to get official word on reporting critical care, go straight to the most common source: the Centers for Medicare and Medicare Services (CMS) Web site, http://www.cms.hhs.gov/default.asp? (you could also check your local Medicare carrier's Web site). There, "you can find out more about what services are included in critical care," for your Medicare insurer,  Long says.

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