Neurosurgery Coding Alert

When your neurosurgeon cares for a very sick patient in the hospital, his medical services -- and the chart documentation -- must meet certain criteria before you can classify them as "critical care."

Last month our experts discussed the importance of understanding what "critically ill or injured" and "high complexity" mean; now check out their advice regarding treatment times and reporting other services with 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]).

The treatment time must exceed 30 minutes -- and that timeframe is not flexible, experts say. If your physician spends less than 30 minutes of critical care time on a particular day, you must report an appropriate E/M code instead of 99291, despite the severity of illness and complexity of decision making and treatment.

Single reporting: Use code 99291 to report the first 30-74 minutes of critical care on a given date, says Caral Edelberg, CPC, CCS-P, of Edelberg Compliance Associations in Baton Rouge, La. "It should be used only once per date even if the time spent by the physician is not continuous on that date," she says.

Until recently the Medicare Claims Processing Manual held on to deleted CPT text that defined critical care as requiring "constant attendance" although CPT guidelines changed the text to "full attention" in 2000.

Medicare considered the CPT changes to be "just editorial in nature," explains Kenny Engel, CPC, CHC, ACS-EM, CCP-P, compliance officer for Martin Gottlieb and Associates in Jacksonville, Fla.

"The problem is that physicians are still under the assumption that critical care time must be constant or continuous," Engel says. "'Constant' actually was meant to indicate 'constancy of mind' or 'steadfast resolution'-- in other words, managing the patient's care dominates the physician's mind and requires his or her full attention."

Good news: Your neurosurgeon doesn't need to constantly be at the patient's bedside to report 99291 or +99292. "The critical care codes are used to report the total duration of time spent by a physician providing services to a critically ill or injured patient, even if the time spent by the physician on that date is not continuous," Edelberg says.

That means you can report cumulative time your physician spends reviewing lab test results, discussing the patient's care with other medical staff in the unit or at the nursing station on the patient's floor. If the physician leaves the hospital unit or devotes time to another patient while treating the critically ill patient, however, that doesn't qualify as "full attention." You'll need to carve out the time spent on other patients or in other areas from your critical care reporting.

Critically ill patients often require the care of multiple physician specialists, so check your neurosurgeon's work against that of other physicians.

"Each provider may report critical care services as appropriate, but only one provider per specialty may report services for a given hour of critical care, even if more than one physician provided care during that hour," says Mary Mulholland, MHA, RN, CPC, with University of Pennsylvania Health System in Philadelphia. "It's important to coordinate critical care billing with other providers to avoid billing overlap."

The critical care codes encompass many services. That means you need to pay special attention to other care you might report with 99291 and +99292. When submitting for critical care services, CPT guidelines state that you cannot separately code the following procedures (although the time spent performing them is considered critical care time):

• interpretation of cardiac output measurements (93561, 93562); x-rays (71010-71020); pulse oximetry (94760-94762); blood gases, and information data stored in computers (such as ECGs, blood pressures, hematologic data [99090])

• gastric intubation (43752, 91105)

• temporary transcutaneous pacing (92953)

• ventilatory management (94002-94004, 94660, 94662)

• vascular access procedures (36000, 36410, 36415, 36591, 36600).

Any procedures not listed above can be coded in addition to 99291 and, as appropriate +99292, but you can't count the time spent performing them. Procedures that fall in this category include common services such as endotracheal intubation (31500, Intubation, endotracheal, emergency procedure), chest tube placement (32551, Tube thoracostomy, includes water seal [e.g., for abscess, hemothorax, empyema], when performed [separate procedure]), and central venous catheter placement (36555, Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age or 36556, ... age 5 years or older).

Example: Your neurosurgeon provides critical care service to a 36-year-old patient for 48 minutes. During the encounter, he spends nine minutes placing a central venous catheter. You'll report 99291 for 39 minutes of critical care and 36556 for the catheter placement. "Remember your claims should be audit defensible," Edelberg says. "Consider a review for cases with questionable medical necessity or all critical care greater than two billed hours."