General Surgery Coding Alert

Not all ICU patients are critical, and not all critical patients are in the ICU If reporting adult critical care services (99291-99292) leaves you with more questions than answers, here's the help you-ve been searching for.

The five question-and-answer scenarios below should solve all of your most common critical care dilemmas. 1. What Qualifies a Patient for Critical Care? A critical care patient must be -critically ill- or -critically injured,- according to CPT guidelines. A critical illness or injury -acutely impair[s] one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition.-
 
-In other words, the patient is in immediate, mortal danger without continued, high-level physician involvement,- says Caral Edelberg, CPC, CCS-P, president, chief executive officer and founder of Medical Management Resources of TEAMHealth in Jacksonville, Fla.

Conditions that could call for critical care include (but are not limited to) central nervous system failure, circulatory failure, shock, and renal hepatic, metabolic and/or respiratory failure, according to CPT instructions.

Important: You may use critical care codes for a -stable- patient, but only if the physician's continued focused attention is preventing the patient's condition from deteriorating further.

-If the condition doesn't have the possibility of becoming a truly life-threatening situation, it's probably not critical care,- Edelberg says. Critical Care Bonus Tip 1: -Critical- Isn't a Place You cannot use critical care codes simply because the patient resides in an -intensive- or -critical- care unit, including coronary care units, respiratory care units or an emergency care facility. By the same token, a patient needn't be housed in such a unit to qualify for critical care.

The bottom line: Although physicians usually end up treating critical care patients in the designated critical care unit (CCU) or intensive care unit (ICU), critical care can take place anywhere in the hospital, says Valrie Hall, CCS, with Peak Health Solutions.    
Example: The surgeon attends to a patient with a large penetrating wound who has gone into shock and respiratory failure. The surgeon is able to stabilize the patient after 30 minutes, but his condition remains such that he could -go either way.- After another three hours, the patient stabilizes to the point that he is no longer in immediate danger of death.

In this case, you can report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 74 minutes and +99292 (- each additional 30 minutes [list separately in addition to code for primary service]) x 5 for the remaining [...]