Part B Insider (Multispecialty) Coding Alert

Published on Fri Aug 04, 2006 PDF

Pay attention to diagnosis codes, time-based documentation

You may think you should write off reimbursement for critical care that happens during the global period for a surgery--but you could be losing out on valuable services.

Example: A patient with non-reducible, right-sided inguinal hernia, CHF, and controlled Type II diabetes comes to the hospital for a hernia repair. Three hours after the operation, the patient shows signs of shortness of breath, problems urinating, cyanotic extremities and an irregular pulse. Soon after the physician arrives at the patient's bedside, the patient goes into cardiac/respiratory arrest, and the physician resuscitates the patient using CPR, IV medications and intubation/ventilation.

Coding: You should be able to bill for the critical care in this scenario using the 24 modifier (Unrelated E/M service by the same physician during postoperative period), says Marie West with Medical Data Services in Edmund, OK. Some carriers may prefer the 25 modifier (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for critical care on the same date as a procedure.

Example: Cigna Medicare asks you to use the 25 modifier for critical care on the same date as a procedure, in its March/April 2000 bulletin. Medicare no longer bundles services such as endotracheal intubation (31500) or Swan-Ganz catheter insertion (93503) into the critical care codes, Cigna pointed out, so you can bill for same-day critical care using the 25 modifier.

You should use an ICD-9 code between 800.0 and 959.9 (except 930-939) with critical care codes 99291-99292, says Noridian Administrative Services in its latest provider question-and-answer file. These diagnosis codes will clearly indicate that the critical care was unrelated to the surgery, Noridian explains.

"Any serious unexpected adverse event after surgery that meets the CPT definition of 'critical' would work, as long as it had nothing to do with the reason for the surgery," notes Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, TN.

Just remember: The critical care codes need documentation to support the severity of the illness as well as the complexity of the physician's decision-making, says Jennifer Swindle, senior coding consultant with PivotHealth in Nashville, TN. You should document all the time the physician spent in detail.

Don't forget: You can't share critical care services between a physician and a non-physician practitioner, such as a physician assistant or nurse practitioner, says West.