Medicare Compliance & Reimbursement

Hone your critical care coding skills now and avoid denials later Your physician documents that a patient suffered a serious "critical" injury and underwent major surgery. You should report a critical care code along with the procedure code because the patient was critically ill, correct? Wrong. You must meet all three of the following key criteria to report critical care services: 1. The patient must meet the definition of critically ill or critically injured. 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. 2. The physician must perform critical care services. Critical care requires high-complexity decision-making to assess, manipulate and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient's condition. 3. Critical care services require a cumulative time of at least 30 minutes on a given date of service. Time can be continuous or intermittent on the date of service and must be clearly documented in the medical record. Reality: If you report critical care codes inappropriately, the denials will pile up. Make sure you're confident when "critical" cases cross your desk by following these expert tips. Before you 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]), you should review how CPT defines a critical care patient. According to CPT, the patient must have "a critical illness or injury [that] acutely impairs one or more vital organ systems." Here's the catch: This condition is one of the most common reasons that many services often do not fit the critical care definition. Even very complex surgeries with major complications may not lead to a physician caring for a life-threatening failure of an organ system such as the heart or lungs. Example: While your physician is performing a transurethral resection of the prostate (TURP), the patient has a heart attack. The physician calls in a cardiologist who performs critical care treatment. Even if the lifesaving measures qualify for critical care, the cardiologist, not your physician, will report the critical care codes. Your other option: If your physician's services do not meet the criteria for critical care services, you should not report 99291 or 99292. "If all criteria are not met to report a critical care code, the physician would report the appropriate E/M visit and service level documented in the medical record" (such as subsequent hospital care codes, 99231-99233; or inpatient consultation codes, 99251-99255), says Cindy Parman, CPC, CPC-H, RCC, [...]