General Surgery Coding Alert

Question:One of the surgeons in our practice thinks that when he rounds on a patient in the intensive care unit (ICU), we should bill critical care codes. Is it correct to use these codes just because the patient is in critical condition?

Louisiana Subscriber

Answer: No, you should not bill the 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]) simply because the place of service is the ICU and the patient is in critical condition.

Here’s why: Critical care is not location based; instead, it describes a type of care. The physician must meet three criteria before billing for critical care:

• The patient must have a critical illness or injury (usually defined as a critical organ system failure or a shock-like syndrome with a high probability of imminent or life threatening deterioration in the patient's condition)
• The physician must document at least 30 minutes of time spent directly with the patient or in the hospital unit, limited only to 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 to prevent further deterioration of the patient’s condition.

Better option: If your physician evaluates a patient in the ICU but does not perform critical care services, you’ll report an initial hospital care code such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...) or an appropriate subsequent hospital care code (99231-99233).