Neurosurgery Coding Alert

Many coders get nervous when claiming critical care. CPT devotes extensive explanatory text to the critical care codes (99291 and 99292), and the requirements for reporting can seem daunting. But if you can establish just two points - the potentially life-threatening nature of the patient's condition and that the physician spent at least a half-hour attending exclusively to that patient - critical care coding shouldn't intimidate you. Point 1: Critical Care = a Serious Threat If you're coming up short on critical care coding, most likely your documentation is to blame, says Caral Edelberg, CPC, CCS-P, president, chief executive officer and founder of Medical Management Resources, a TeamHealth Company in Jacksonville, Fla. "We see cases that could be critical care yet can't be billed because the documentation just isn't enough to support the selection of the critical care code," she says.
 
As a first step to correctly reporting 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 must be able to identify (and document) patients who are "critically ill" or "critically injured," which is the minimum requirement for claiming critical care.
 
A critical illness and injury is one that "acutely impair[s] one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition," according to CPT. CPT further specifies, "Critical care involves high-complexity decision-making to assess, manipulate and support vital system functions, to treat single or multiple vital organ system failures and/or to prevent further life-threatening deterioration." In other words, a critical care situation involves a physician with the highest level of preparedness intervening urgently to stop a patient's condition from becoming worse.
 
A patient's condition may be stable, but if the physician's focused attention is keeping the patient stable, you should be using critical care codes. On the other hand, you cannot use critical care codes simply because the patient resides in a "critical care" unit. "With critical care, you're talking about a situation where the patient could go either way," Edelberg says. "If it doesn't have the possibility of becoming a truly life-threatening situation, it's probably not critical care."
  
For example, an automobile hits a pedestrian on a dark street. The victim suffers multiple traumatic injuries, including head injuries, which require immediate, constant and high-level attention. For four hours following admission, the patient shows signs of intracranial hemorrhage that require a "high level of physician preparedness and intervention," and therefore qualifies as critical care. But when the patient's condition stabilizes such that the immediate threat of death or loss of significant function is unlikely and, specifically, frequent [...]