Pulmonology Coding Alert

Reporting critical care on the same day as other services or procedures can be near impossible, but you can learn proper coding guidelines that will enable you to break the gridlock on these claims.

The problem occurs because critical care coding guidelines are stringent when it comes to the documentation needed to support medical necessity and to show that multiple services are warranted. Since a doctor's time spent with critical care patients is often complex and in-depth, it is hard to sift through the rules pertaining to time spent with patients, coverage of specific procedures, and medical necessity. Therefore, you need to be clear on what is required in order to get proper reimbursement for your time spent with critical care patients.

It is often necessary to provide critical care services on the same day as other E/M services. Although tricky, it is possible to bill for both services on the same day and get full reimbursement. According to Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm based in Lansdale, Pa., documentation and careful coding are the keys to billing for multiple E/M visits. You need to follow a few simple guidelines to optimize your reimbursement.

For example, a patient is admitted in the morning for asthma and, later in the day, goes into respiratory arrest. You would "bill the hospital admission code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of other service) and add up all of the time spent on critical care, and bill the codes (99291-99292) accordingly," says Renee Brown, CPC, Southeastern Lung Care, Conyers, Ga. Make sure to distinguish between the two services by using different diagnosis codes.

According to Falbo, an important tip is to associate the most specific diagnosis code that explains the critical care condition with the critical care service. The level of specificity is important because payers do not see progress notes. The linkage of codes that support medical necessity for critical care is important so that the payers, upon review of the documentation, do not downgrade the critical care service to a subsequent hospital care visit. The diagnosis codes from the 493.xx series (Asthma) would match the hospital inpatient code (99221-99233), and the respiratory arrest code (799.1) would match the critical care code (99291-99292).

There may be circumstances in which the physician sees a patient in an outpatient setting for a regular office visit and later sees the patient for critical care. For example, a 65-year-old woman undergoes an exam for emphysema. The exam is completed, and she is sent home. Later that same day, the woman returns with shortness of breath. While at the office, the patient goes into respiratory arrest and enters a critical care state.

The Medicare Carriers Manual states that when an outpatient service is performed that does not require critical care, and later the patient requires critical care, both the critical care and the E/M services may be paid. Be sure to include different diagnosis codes for each service. The diagnosis for the office visit should be emphysema (492.0-492.8), and the diagnosis for the critical care service needs to be respiratory arrest (799.1). Brown says that modifier -25 should be appended to the office visit in this circumstance also.

If the patient had undergone respiratory arrest during the earlier visit and required critical care services, then the only service reported should be critical care.

Deciding whether to bill for critical care on the same day as a surgical procedure can be somewhat tricky. The Medicare guidelines depend on the type of surgery performed one with a 0-, 10- or 90-day global surgery period. However, most surgeries that pulmonologists perform are minor surgeries or endoscopies with a postoperative period of 0 or 10 days. For example, Upstate Medicare Division of New York (UMD) says in its policy guide that "visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a separately identifiable service is also performed." If the postoperative period is 10 days, visits or procedures related to the surgery are not separately payable. If the period is 0 days, payment for postoperative visits is appropriate.

UMD states that postoperative critical care services provided during a global period for a seriously injured patient that are not related to the surgery are payable under the following circumstances: