Neurology & Pain Management Coding Alert

Question: What can you tell me about the codes for critical care? One of our neurologists wants to use these codes, but I am unfamiliar with them.

Iowa Subscriber  

Answer: 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]) describe direct delivery by a physician of medical care for a critically ill or critically injured patient, according to CPT. To meet the standard of critically ill or injured, CMS specifies that there must be a high probability of sudden, clinically significant or life-threatening deterioration in the patients condition that requires the highest level of physician preparedness to intervene urgently.
 
Further, critical care services require direct personal management by the physician. They are life- and organ-supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of or failure to initiate these interventions on an urgent basis likely would result in sudden, clinically significant or life-threatening deterioration in the patients condition.
 
In other words, care of a critically ill patient (or the presence of a patient in a critical care ward) alone cannot qualify as critical care: Constant, high-level physician involvement must be shown to be medically necessary. This also requires that the physician devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same time. Only one physician at a time can claim critical care for a given patient.
 
To claim 99291, the physician must document a minimum of 30 minutes. If he or she documents fewer than 30 minutes of critical care, report the service using another appropriate E/M service code (for example, 99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...). Report only one unit of 99291 per claim. You should bill each additional 30 minutes of critical care beyond the first 74 minutes using add-on code 99292, as follows:
 
  99291, 99292: 75-104 minutes
  99291, 99292 x 2: 105-134 minutes
  99291, 99292 x 3: 135-164 minutes
  99291, 99292 x 4: 165-194 minutes, etc.
 
Note: Because 99292 is a designated add-on code, modifier -51 (Multiple procedures) is not necessary.
 
According to CPT, critical care time need not be continuous, but because these codes are time-based, documentation is crucial. Medical notes should include all start and stop times, but the total critical care time is sufficient (especially because it is often discontinuous). Neither CPT nor CMS limits the total critical care time that may be claimed per day or per patient. Some carriers may request documentation for cases in which the claimed amount of care appears [...]