Gastroenterology Coding Alert

Question: If our gastroenterologist saw a patient in the ICU for a consultation, can I report the critical care code 99291 and 99292 as our clinician saw the patient in the ICU of the hospital?

North Carolina Subscriber

Answer: Just because the location in which your gastroenterologist saw the patient was the intensive care unit (ICU) of the hospital, it does not justify for you to use critical care 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 [List separately in addition to code for primary service]) to report the services of your clinician for the patient.

Instead, you will have to discern whether the services provided by your gastroenterologist qualify for you to report the critical care services codes, 99291 and 99292.

Essential distinction: Critical care is not location-based; rather, it describes a specific kind of care. You must meet the following criteria to bill for critical care:

• The patient must have a critical illness (usually defined as a critical organ system failure or a shock-like syndrome);
• The physician must document at least 30 minutes of time spent directly with the patient or on the floor (hospital unit) limited only for that patient;
• The physician must document highly complex decision making to assess, manipulate, and support vital system function(s) to treat the critical illness or prevent further deterioration of the patient’s condition.

Typically, the physician providing critical care monitors the patient for an extended time and obtains opinions and advice from multiple specialties (including cardiology) to create an overall care plan.

However, if the services provided by your gastroenterologist did not meet the requirements of critical care, you will have to report the appropriate consultation code, 99253 (Inpatient consultation for a new or established patient ...) instead. For Medicare or other payers not accepting consultation codes, you will have to report an initial hospital care code such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...).