Neurology & Pain Management Coding Alert

Payment policy changes for 37195 mean you-ll need to rely on 99291-99292 If your payment for t-PA administration leaves something to be desired, your practice may be inaccurately reporting this service based on correctable misconceptions of critical care codes.

Take stock of these common 99291-99292 pitfalls to make sure you-re not falling prey to critical care no-no-s.
 
Myth #1: Since critical care is the highest level of E/M, you need to satisfy all the E/M elements. Reality: Actually, 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]) are time-based codes--and if you look carefully at the code descriptor requirements in CPT, you-ll find no specific requirements for history, physical exam and medical decision-making (MDM).

-Most of the codes in the E/M section of CPT have specific key element requirements with regard to history, physical exam, and medical decision-making,- says Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI, an ED billing company in Stoneham, Mass.
 
For example, to report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity), you need a comprehensive history, comprehensive physical exam, and high-level MDM--but those requirements aren't present for critical care, Granovsky says. -These are time-based codes that also require a high probability of imminent or life-threatening deterioration in the patient's condition.-

That time must include at least 30 minutes of care, excluding any separately billable procedures the physician performs, such as t-PA administration. To report this service for stroke patients, pair critical care codes with 37195 (Thrombolysis, cerebral, by intravenous infusion).

Reimbursement heads-up: In the 2006 physician fee schedule, 37195 has a -C- status, meaning that individual carriers can determine the reimbursement level. In practical terms this means that many carriers will opt to pay nothing for this code. If you don't want your neurologist giving away his services, you-ll need to properly report critical care codes. Myth #2: Critical care must take place in the CCU or ICU. Reality: While 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. According to CPT, critical care isn't specific to any location, such as an ICU or CCU. What determines whether you can report 99291 is the patient's critical condition, Hall says.

If necessary, the physician can perform critical care on the [...]