Primary Care Coding Alert

Coding professionals who monitor critical care service codes noticed several significant changes earlier this year. These adjustments increased opportunities for family physicians to report critical care services but, ironically, they also triggered a reduction in the work relative value units (RVUs) associated with these codes.

Last year, critical care specialists recommended that the American Medical Association modify CPT definitions for critical care, in many instances relaxing the circumstances under which they can be assigned. Specifically, services that coders previously reported as subsequent hospital care (evaluation and management codes [E/M] 99231-99236) are now categorized as critical care. The critical care codes modified in CPT 2000 include 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]).

The Health Care Financing Administration (HCFA), which has long kept a close eye on the use of critical care codes, reacted to the adopted changes by reducing reimbursement received for these services. According to Daniel S. Fick, MD, associate professor, residency director and medical director for the Department of Family Medicine at the University of Iowa College of Medicine in Iowa City, the change in critical care RVUs represents a decrease in reimbursement of about 10 percent.

Patient Not Required to Be Unstable

The most significant example of the changes in critical care coding is the deletion of the word unstable from the descriptions for 99291 and 99292. This is a noteworthy change, coding professionals point out, because it includes conditions previously not categorized as critical. In the past, these would have been reported with one of the subsequent hospital care codes (99231-99233).

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., agrees. This new definition relaxes the times when coders can appropriately report these critical care codes. A physician may see a patient who is critically ill or injured, but whose condition may not be defined as clinically unstable. In the past, we could not assign a critical care code for these services. Now we can.

For instance, a patient may be admitted to the intensive care unit (ICU) after a significant cardiac event. His vital signs have normalized, but his condition continues to be critical. In the past, family physician services while treating this patient would have been coded with the appropriate E/M code. Because CPT 2000 has removed the requirement that the patient be unstable, services could now be coded with 99291 for the first 30-74 minutes of care and 99292 for each additional 30 minutes, if all other requirements for critical care services are met (see Defining Critical Care on page 45).

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