Pulmonology Coding Alert

Time and documentation are the keys to getting reimbursement for your pulmonologist's critical care services

Critical care coding guidelines are stringent when it comes to the documentation needed to support medical necessity. Follow these tips to sift through the rules and understand the requirements for getting proper reimbursement for your physician's time spent on critical care services. Look Closely at CPT's Definition of Critical Care Before you use critical care 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]), you should review how CPT defines a critical care patient.

According to CPT, the patient must have "a critical illness or injury [that] acutely impairs one or more vital organ systems" and requires the pulmonologist to perform "decision-making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple organ system failure, or to prevent further deterioration."

A physician needs to document that the patient is critically ill, which requires that the patient has at least one organ system that is failing and that the patient's life is in jeopardy, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. Without documentation of these criteria, you can't report critical care codes.

If your pulmonologist's services do not meet the criteria for critical care services, you should not report 99291 or 99292. You'll have to use another appropriate E/M service code (such as subsequent hospital care codes, 99231-99233; or inpatient consultation codes, 99251-99255), depending on the level of service the physician provided. Critically Ill Doesn't Equal Critical Care Just because your pulmonologist is providing care to a critically ill patient, you shouldn't automatically assume you can code his services using critical care codes.

Example: If a pulmonologist makes rounds in an intensive care unit (ICU), you shouldn't assume this is critical care because you may not meet the time requirements for critical care.
 
A patient who is intubated for acute respiratory failure (518.81) and is improving or even stable may not be considered critically ill, particularly if the physician's service does not require his constant attention toward the care of the patient. Because the requirements for critical care have not been met, you cannot report critical care codes for the physician's services in this case.

Note: A patient does not have to be in the intensive care unit (ICU) to be critically ill, and similarly, not every patient in ICU is critically ill, says Pierre [...]