Prove Patient Is Critical Before Coding 99291
Published on Sat Jan 05, 2008
Remember to count bundled services toward critical care time
When the pulmonologist treats a patient with a serious injury or medical condition, coders should be on the lookout for possible critical care services. After all, these codes sport higher relative value units (RVUs) than the standard E/M codes.
But be careful you don't miscode a claim in your zeal to use the high-RVU critical care codes. You'll have to prove that the patient needed critical care services before considering 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (... each additional 30 minutes [list separately in addition to code for primary service]), or you'll likely receive a denial for your claim.Establish Critical Illness or Injury FirstAccording to CPT, a patient must be critically ill or injured for critical care services.
Critical illness or injury is defined as impairment of one or more vital organ systems such that there is risk of imminent or unstable life-threatening deterioration in the patient's condition.
Critical care involves high-complexity medical decision-making to assess and support the functionality of vital organ systems--all in an effort to prevent the patient from deteriorating further, says Shelley Bellm, CPC, coder at Colorado Mountain Medical.
Translation: Critically ill or injured patients require immediate medical attention, or they will get worse--or die, says Michael Lemanski, MD, billing director at Baystate Medical Center in Springfield, Mass.
Check out this definition from Medicare: "Critical care includes the care of critically ill and unstable patients who require constant physician attention, whether the patient is in the course of a medical emergency or not."
But "constant physician attention" does not necessarily mean constant physical contact with the patient. When you report critical care time, Medicare wants you to report "the time the physician spent working on the critical care patient's case, whether that time was spent at the immediate bedside or elsewhere on the floor, but immediately available to the patient."
So time spent "reviewing laboratory test results or discussing the critically ill patient's care with other medical staff in the unit or at the nursing station on the floor would be reported as critical care, even if it does not occur at the bedside," Medicare states.
Consider this example: The pulmonologist meets a 67-year-old established patient with chronic obstructive pulmonary disease (COPD) at the hospital. The patient is in severe respiratory distress with an acute exacerbation of his underlying lung disease. Despite multiple rounds of nebulizers, treatment with steroids, and additional supplemental oxygen, the patient develops worsening respiratory distress and ultimately suffers acute respiratory failure and requires intubation.
The physician documents that she spent 45 minutes of time outside of separately billable procedures caring for this critically ill patient.
On the claim you would report [...]
