Oncology & Hematology Coding Alert

Question: Are there any advantages to choosing critical care codes rather than high-paying E/M codes?

New Hampshire Subscriber Answer: Even though you should first choose the appropriate E/M code based on proper coding and documentation, an advantage to using critical care codes (99291-99292) is that you may find that your local carrier pays more for those codes than for high-level E/M codes (for example, 99205 and 99215).
 
For instance, HGSAdministrators (HGSA) in Pennsylvania pays about $256 for 99291. On the other hand, if you submitted level-five new patient code 99205 to HGSA, you could expect about $180, a difference of $76. But to improve your reimbursement, you must medically justify using 99291-99292, or your insurer may deny your claim.
 
Often oncology coders resist using 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]), because they believe the codes are meant for hospitals.
 
You may use these higher-paying codes in the office if you follow CPT's guidelines for reporting critical care services. For three key points of CPT's definition of critical care, review the following:

   CPT defines a critical illness or injury as one that impairs one or more vital organ systems. This creates a high probability of imminent or life-threatening deterioration in the patient's condition.
   In critical care, the physician treats single or multiple vital organ system failure(s) and/or prevents further life-threatening deterioration of the patient's condition. The physician must continue these life-sustaining services for 30 minutes to qualify for 99291.
   Although the physician does not usually provide these services in the office for an extended time, he or she may perform them until the patient can be transported to a hospital or critical care unit.