Podiatry Coding & Billing Alert

Hint: Critical care is not based on the location of service; instead, this term describes a type of care.

If your podiatrist uses high-complexity decision-making to assess, manipulate, and support vital system functions to treat a patient who suffers from vital organ system failure or to prevent further life-threatening conditions, you may be able to report the critical care evaluation and management (E/M) codes — 99291 and +99292.

However, the CPT^® manual details very specific circumstances under which you can appropriately report critical care. If you don’t know the rules, your podiatrist’s claims could be in serious jeopardy.

Take a look at the following tips to confidently report critical care services for your podiatrist.

Tip 1: Report Critical Care With 99291, +99292

You can report 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)) for critical care.

Critical care occurs when a physician or other qualified healthcare professional directly provides medical services for a critically ill or critically injured patient. As always, the documentation must support the necessity of the critical care service.

Tip 2: Always Meet Certain Requirements to Qualify for Critical Care

To qualify for critical care, a service must meet all of the following requirements:

• The patient must be critically ill/injured — have vital organ failure or a life-threatening health condition.
• The physician must perform the critical care services, including using high-complexity decision making to assess, manipulate, and support vital system functions to treat vital organ system failure or to prevent further life-threatening conditions.
• All critical care services must last at least 30 minutes on a given date of service. The time can be continuous or intermittent.

There must be documentation of a critical illness or injury that acutely impairs one or more vital organ systems leading to imminent or life-threatening deterioration in the patient’s condition, explains Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, president and CEO of SLG, Inc. Consulting in Raleigh, North Carolina. However, just because a patient is critically ill or injured or in the ICU, doesn’t mean the care should automatically be a critical care service.

“Critical care services can be provided anywhere, in an ED, a Med/Surg room, a clinic, PACU, or even the hospital parking lot, but there must be clear evidence of medical necessity and intensity of care beyond the standard E/M codes, and the physician must be immediately available to the patient,” Goodman says. “Thus, documentation of the patient’s condition, complexity of medical decision-making, interventions performed, and time spent providing critical care services are vital to correct coding.”

Bottom line: Critical care is not based on the location of service, but instead, the term describes a type of care. Therefore, the critical care codes must be in line with the aforementioned criteria, not the place of service.

Tip 3: Beware Services Bundled Into Critical Care

The CPT^® critical care guidelines includes a specific list of services bundled into critical care that you should not report separately when performed by the physician providing the critical care during the critical care period. They are as follows:

• The interpretation of cardiac output measurements (93561, 93562)
• Pulse oximetry (94760-94761, 94762)
• Blood gases, and collection and interpretation of physiologic data (eg, ECGs, blood pressures, hematologic data)
• Chest x-rays, professional component (71045, 71046)
• Gastric intubation (43752-43753)
• Temporary transcutaneous pacing (92953)
• Ventilator management (94002-94004, 94660, 94662)
• Vascular access procedures (36000, 36410, 36415, 36591, 36600).

Don’t miss: When your physician provides any of the above services during a critical care session, do not report them separately. However, facilities can report these services separately.

Tip 4: Mind Time for Critical Care

Time is a vital component of the critical care codes. The physician should always record the time he spent with the patient in the medical documentation.

You should report 99291 for the first 30-74 minutes of critical care on a given date. You should report 99291 only once per date even if the time the physician spends is not continuous on that date. You should report critical care of less than 30 minutes total duration on a given date with the appropriate E/M code, not a critical care code.

Then, you should report +99292 for additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes.

Coding tip: Per CPT^® guidance, if a code is time-based, like the critical care codes, no record of total time spent would create a service that is non-billable, says Shannon O. DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, partner at DoctorsManagement, and president of NAMAS in Melbourne, Florida.

“Coders/auditors who work on behalf of providers are encouraged in these instances (within a reasonable time threshold) to query the provider,” DeConda explains. “Queries are perfectly reasonable as long as they are not promoting upcoding and are worded appropriately.”

DeConda offers this example of a solid query if a provider were lacking time in the medical documentation: “Dr. Brown, upon reviewing Patient X’s encounter from yesterday, there was not a time statement for the critical care service. Could you review this encounter for any missing relevant information?” In this instance, you are merely asking the provider to review for additional information, according to DeConda.

On the other hand, in a query, you should never say something like “Hey, Dr. Brown, please review Patient X and add a statement of greater than 31 minutes was spent…. Also note, that the patient was just seen yesterday,” according to DeConda.

Tip 5: Make Sure Time Spent in Critical Care Meets Criteria

“The time that can be reported as critical care is the time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit,” according to the CPT^® guidelines.

You can report critical care: The physician can report the time he spends on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff, or documenting critical care services in the medical record as critical care, even though these services did not occur at the patient’s bedside.

Also, “when the patient is unable or lacks capacity to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient,” per the guidelines.

Don’t report critical care: However, any time the physician spends in activities outside of the unit or floor, such as telephone calls he takes at home, in his office, or somewhere else in the hospital, would not count as critical care because the physician is not immediately available to the patient in these circumstances.

Additionally, if the physician spends time in activities that do not directly contribute to the patient’s treatment, such as administrative meetings, he cannot report these services as critical care, even if he performs these activities in the critical care unit, according to the guidelines.