Part B Insider (Multispecialty) Coding Alert

Reader Questions:

Confront Potential Coding Discrepancies

Published on Fri Jul 03, 2015

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Question: We disagree with our emergency physician’s documented level of care for one of his critical care patients. The physician documented critical care time minutes, but upon review of the medical record, we don’t think the patient’s condition warrants this level of care or meets the requirements for administering critical care. We want to code the report as a level five E/M service. Any suggestions as to whether we can, or should, code for a different service than the physician chose to perform?

Answer: If you have good cause to question the necessity or length of the critical care time your physician provided, you should probably review the patient record with the physician. You should then code according to the reviewed decision.

Before you go into the review with your physician, make sure you know exactly why you should down code to the level 5 E/M code, 99285. Check on your critical care guidelines.

Remember a patient’s condition warrants critical care, even if the danger isn’t presently life threatening to the patient’s health. Many coders get tripped up on that nuance. The guidelines state that a crucial illness of injury is one that “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration.” So, even if your patient isn’t in a life-threatening situation but the possibility is likely, then your physician needs to provide critical care.

Check over the guidelines for other details, including critical care time and other services provided during that time.