Neurology & Pain Management Coding Alert

How would you like to improve your E/M reimbursement by 50 percent or more when the neurologist attends to a seriously ill or injured patient? It's not as hard as you think. Just four easy steps can teach you when to report critical care instead of office or inpatient visit codes, thereby raising your revenue and improving your coding accuracy. 1. Determine if the Patient's Condition Is 'Critical' CPT provides two time-based codes to report critical care: 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]). To apply these codes effectively, you must document that the patient is critically ill or critically injured and therefore requires the direct personal management of and frequent, personal assessment and manipulation by a physician. A common example of a neurologist using critical care codes occurs when a stroke victim requires t-PA administration, says Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting in Manassas, Va. She says that intravenous administration of t-PA in stroke victims has a 12 percent risk of fatal cranial hemorrhage and requires constant physician attendance. The situation is potentially life-threatening and, if you document it as such, critical care codes are appropriate. "Critical care codes are among the highest-paying evaluation and management services. Payers are going to review such claims with special scrutiny, and you want to be sure you document all the important points," Castillo says. A critical illness or injury acutely impairs one or more vital organ systems "such that the patient's survival is jeopardized," CPT states. CMS regulations further specify that with a critical illness or injury, "There is a high probability of sudden, clinically significant or life-threatening deterioration in the patient's condition that requires the highest level of physician preparedness to intervene urgently." "In other words, without immediate and high-level physician care, the critically ill or injured patient likely will not live," Castillo says. When reporting critical care codes, you should state specifically in the documentation what makes the patient's condition critical, says Linda Laghab, CPC, coding department manager for Pediatric Management Group at Children's Hospital, Los Angeles. Vital organ system failure could include, but is not limited to, central nervous system failure, shock and/or respiratory failure. 2. Demonstrate That Care Is Medically Necessary You may report critical care for a critically ill, injured or postoperative patient only if such care is medically necessary. "Providing medical care to a critically ill patient should not be automatically determined to be a critical care service for the sole reason that the patient is critically ill," CMS regulations specifically state. For example, a [...]