Neurosurgery Coding Alert

Question: My practice has a heavy trauma volume and manages critical care issues for head-injured patients whom I have operated on (e.g., craniotomy). Can I use critical care codes (e.g., 99291-99292)? If another physician is also using a critical care code on the same day for that patient, can we both use the same code?

David McKalip, MD
St. Petersburg, Fla.

Answer: Medicare and most insurance companies will usually only pay for critical care services administered to a given patient for one physician per day. Unfortunately, it is on a first-come, first-serve basis. But two physicians critical care charges can be allowed on appeal, with proper documentation, if the critical care required that the physicians bedside presence was required due to the patients unstable condition.

The neurosurgeon, however, would be able to charge only for critical care services if the care being provided is unrelated to the craniotomy (which has a 90-day global period). If, for example, the patient had multiple head trauma and the craniotomy was performed to treat only one of two or more injuries, detailed documentation would be needed to support that the injury for the critical care was unrelated to the craniotomy.

Note: Medicare and CPT have different standards. Thus it is probably beyond the scope of the normal uncomplicated followup care that is included in surgery for non-Medicare patients. For Medicare, it must be related to other conditions than what the craniotomy was for e.g., brain contusion vs. subdural hematoma.

The neurosurgeon should state clearly what time was spent on postoperative care and on critical care services that day rather than total time spent. Medicare requires that this time be separately documented.

Finally, the neurosurgeon needs to use modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) on the critical care services to indicate that a separate and identifiable evaluation and management service was performed during a postoperative period.