Pulmonology Coding Alert

Patient condition, not location, drives proper coding

When your pulmonologist provides critical care outside the emergency department or other designated "critical care area," your claim will be snag-free, provided you meet two important documentation requirements: time and severity

Do: Code Critical Care in Non-Traditional Settings

If you think that your physician has to be in an emergency department (ED) or other designated "critical care area," you may be missing out on well-deserved reimbursement.

In other words, no matter the setting, critical care is based on the physician's time spent caring for the critically ill or critically injured patient, meaning there is a high probability of imminent or life-threatening deterioration of the patient's condition, experts say.

Although most critical care occurs in an emergency department or other designated "critical care area," Medicare pays for critical care provided in any location if you meet the requirements. Conversely, a patient's presence in an intensive or critical care unit doesn't solely justify critical care billing.

Don't: Skimp on Your Critical Care Documentation

Although the critical care may have occurred in a non-traditional setting, the service is still a viable critical care claim -- as long as you meet documentation requirements, experts say.

Document "start and stop" or cumulative time spent on all care the physician provides on a given calendar day. If the pulmonologist provides critical care and another service in the same session, specifically exclude minutes spent rendering separately billable procedures and indicate in the note that the critical care time does not include procedure time.

These services would include the usual E/M components. Other services that may (or may not) be part of a carrier's critical care package include:

• interpretation of cardiac output studies
• chest x-rays
• blood gases
• electrocardiograms
• blood pressures
• ventilation management
• vascular access procedures.