Gastroenterology Coding Alert

Answer: Although the concept of coding based on time does not apply to the emergency department codes (99281-99285), this scenario actually meets the criteria for critical care coding, which is based on time. Code the service using 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

In this case, the presenting problem (not the final diagnosis or condition) determines the risk factor. The bleeding could potentially create an unstable, high-risk condition for the patient. According to CPT^®, critical care is necessary when “a critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.” This situation indeed falls under this definition.

Another factor in determining critical care is time. If your doctor does not spend at least 30 minutes attending exclusively to a patient’s needs, it is not critical care. Make sure your physician clearly and thoroughly documents all of the time they spend providing services. Include the site of service, medical necessity, and the services provided.

Also, when deciding whether critical care was achieved, ask yourself the following questions:

• Is the patient alert and stable? Typically, though not always, patients requiring critical care are not alert and have unstable vital signs.
• Are efforts being made to stabilize the patient? Critical care patients are often subjected to interventions, like IV fluid administration and medication administration, designed to stabilize them.
• Has the patient been moved to another department for diagnostic tests? Patients needing critical care are rarely transported for tests that can be conducted with portable technology (for example, chest X-rays). For that reason, you can report critical care services that occur anywhere, including not just the critical care unit, but also the emergency department, observation care, or even your office.
• Has the patient been discharged from the hospital? Those receiving critical care may be transferred to another department, but they are rarely sent home.
• Was the onset of symptoms rapid? Critical care patients can be marked by sudden and surprising symptoms. It is not likely that someone will need critical care for an ongoing issue.

Of course, these questions won’t always lead you to be able to determine a confirmed critical care situation, but they may prompt you to start thinking about whether the service might constitute critical care. When in doubt, ask the gastroenterologist if the patient encounter met the critical care criteria.