Internal Medicine Coding Alert

Published on Fri Jun 05, 2009 PDF

Question: Are there rules stating my physician must have a certain amount of history of present illness (HPI) and review of systems (ROS) to bill critical care time? Our internist documented a physical examination and that he spent 30 minutes with the patient. Can I report 99291 (Critical care, evaluation and management of the critically

ill or critically injured patient; first 30-74 minutes)?

Florida Subscriber

Answer: No, you do not need all the elements of the patients HPI and ROS to report critical care codes when the physician has documented critical care time. Critical care isnt based on any of the data elements associated with E/M levels -- its based on time for the critically ill or critically injured patient. Critical care is defined as the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or lifethreatening deterioration in the patients condition.

Since critical care is a time-based code, you neednt meet all the usual elements with regard to HPI, physical examination (PE), past, family, and social history (PFSH), and ROS usually required for the E/M codes. However, your physicians documentation must reflect the nature of the patients critical illness and that 30 minutes of care was spent outside of separately billable procedures.

The duration of critical care services to be reported is the time your physician spends evaluating, providing care, and managing the critically ill patients care. That time must be spent at the immediate bedside or elsewhere on the floor or unit so long as the physician is immediately available to the patient.

Example: The time spent reviewing lab test results or discussing the patients care with other medical staff in the unit or at the nursing station on the floor may be reported as critical care, even when it does not occur at the bedside. This is so long as this time represents your physicians full attention to the management of the critically ill/injured patient.