Pulmonology Coding Alert

Critical care patients no longer need always be considered unstable critically ill or unstable critically injured under CPTs revised critical care codes (99291-99292).

Lynne Marcus, vice-president of membership and public affairs, the American College of Chest Physicians, says, We removed the word unstable because we felt [the patient] could still be critically ill and have some stable values that come through, says Marcus, who was on the team involved in revising the codes definitions for CPT 2000.

Marcus says that the CPT 1999 definitions proved confusing for carrier medical directors, some of whom were not interpreting critical care definitions in a way that would be most beneficial to our patients. The goal in revising the language for the CPT 2000 manual was to clarify what critical care and intensive care are so that any carrier medical director could pick up this definition, she explains.

Understand the Difference Between 1999 and 2000 CPT

The revised definition says critical care services are the direct delivery by a physician(s) of medical care for a critically ill or injured patient.

The Critical Care Working Group, which comprises of representatives from six national specialty groups, worked with the Health Care Financing Administration (HCFA) to clarify the critical care definition.

The revision marks a significant change from CPT 1999 in the definition of critical care for the codes 99291-99292. Previously, CPT 1999 codes 99291 (first hour defined between 30 minutes-74 minutes) and 99292 (each subsequent 30-minute period) were used for the critical care, evaluation and management of the unstable critically ill or unstable critically injured patient who required constant physician attendance.

Use the critical care codes 99291 and 99292 to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

Marcus says the new critical care definition also reflects a wording change from constant attention to full attention, a change predicated on the working groups belief that you wont always be at the bedside, but youre still spending time taking care of that patient. We felt those were really important. According to the new definition, The physician need not be constantly at bedside per se but is engaged in physician work directly related to the individual patients care.

Tracking Time is Key

According to CPT 2000, the time spent with the individual patient should be recorded in the patients record. The time that can be reported as critical care is the time spent engaged in work directly related to the individual patients care whether that time was spent at the immediate bedside or elsewhere on the floor or unit.
Carel Martin, CPC, CPS, insurance supervisor with Cle Elum Family Medicine Center in the town of Cle Elum, Wash., says that time spent on the floor or unit consulting with a specialist about the critically ill patients care or documenting services in the medical chart is critical care that is directly related to patient care. The services may not be face-to-face, but it is absolutely patient care activity, says Martin. All of that time is reportable from the minute the doctor arrives on the scene, asks the first question, takes the first look, until the doctor is finished.

Use the critical care codes if the patient is unable or clinically incompetent to participate in discussions because time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patients 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 medical decision making.

Martin says that the 99291 code should be used only once per date, even if the time spent by the physician is not continuous on that date. Critical care is billed for the total time spent on the patient, says Martin. You have to have a minimum of 30 minutes to bill for 99291. Any critical care time less than 30 minutes total should be reported with the appropriate E/M [evaluation and management] code [99201-99499].

She also adds that it is important to remember a patient can be placed in a critical care unit but not have her life in danger. In such cases, she states that other E/M codes for hospital visits should be used instead of the critical care codes.

The 99291 critical care service by a physician is only during the actual time when a patient is in critical condition and lack of immediate physician intervention could result in loss of life, Martin explains. Critical care codes are for critical care billing purposes at any time. There are times the patient may have been taken care of in the emergency room or ambulance. By the time they were stabilized and transferred to the critical care unit, they may have been truly stabilized and improving. Such a scenario, she says, would result in regular hospital visit codes (99231-99233, subsequent hospital care).

A number of services are included in reporting critical care when performed during the critical care period by the physician overseeing that care, according to CPT 2000. They include the following:

The interpretation of cardiac output measures
)(93561, 93562)

Chest X-rays (71010, 71020)

Blood gases, and data stored in computers (e.g. ECGs, blood pressures, hematologic data (99090);

Gastric incubation (91105);

Temporary transcutaneous pacing (92953);

Ventilaor management (94656, 94657, 94660, 94662); and

Vascual access procedures (36000, 36410, 36415, 36600).

Procedures performed outside this list should be reported separately, CPT 2000 says.

Critical Care Code RVU Reduced The Health Care Financing Administration (HCFA) issued a final physician payment rule, published in the Federal Register, that included for reimbursement a 10 percent reduction for the critical care codes 99291-99292. This rule, which affects Medicare Part B payments, became effective Jan. 1. Medicares physician payment system is a resource-based system that calculates the physician work according to the time and intensity used for a given service, called the relative work value. HCFA reduced the RVU of the 99291 critical care code to 3.60 from 4.0, and 99292 to 2.0 from 2.2. To obtain a copy of the Federal Register, visit Web site http://www.access.gpo.gov/nara/110299/fr02no99-17.txt Also, in response to the CPT 2000 revised definition of the critical care codes, HCFA in December released a program memorandum, Issues Related to Critical Care Policy, to carrier medical directors that clarifies the Medicare policy concerning both payment for and medical review of critical care services. To obtain a copy of the program memorandum, visit the HCFA Web site at http://www.hcfa.gov/medicare/mcarpti.htm.