Pulmonology Coding Alert

CPT considers many services part of the critical care package

When deciding whether your pulmonologist provided critical care services, you’ll need to ask questions about patient status to determine whether the services actually represent critical care. If you decide a patient did not receive critical care services, you’ll need to rely on other E/M service codes.

Once you have identified an encounter as critical care, you need to meticulously document the critical care time in order to file a proper claim, and you also need to decide which services are part of the critical care package and which ones are separately reportable. Further, you must identify any additional E/M services the physician provides.

There’s a lot to keep straight when you are reporting critical care. Check out this advice on how you can ethically maximize reimbursement for your critical care claims.

Make Sure Patient Is Critically Ill or Injured

You’ll first want to find out if the patient has a critical illness or injury. If the patient is not critically ill or injured, you cannot report critical care services, says Shelley Bellm, CPC, physician relations and coding manager at Colorado Mountain Medical in Edwards.

Patients requiring critical care have acute impairment of one or more vital organ systems, such that there is risk (i.e., high probability) of imminent or life-threatening deterioration in the patient’s condition without intervention, Bellm says. Critical care requires high-complexity decision-making to assess and support the vital organ systems’ functionality to prevent deterioration in the patient’s condition, she says. If the physician provides services such as these for at least 30 minutes, it should be a critical care encounter.

Conditions that might require critical care include acute respiratory failure (518.81), congestive heart failure (428.0, Congestive heart failure, unspecified) and pleural effusion (511.9, Unspecified pleural effusion).

Example: A pulmonologist treats a patient in respiratory arrest in a hospital emergency department. The physician performs cardiopulmonary resuscitation for 15 minutes, then monitors and treats the patient’s respiratory failure for 45 minutes.

Bonus CEU coding scenario: You should report the critical care service and the CPR, Bellm says. When filing this claim:

--report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care

--report 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest]) for the CPR

--link 799.1 (Respiratory arrest) to 92950 and 518.81 (Acute respiratory failure) to 92950 to prove medical necessity for both services.

When documenting this claim, be sure to note the start and stop times for the CPR and the critical care so the insurer knows how much critical care time you are coding for. Also, know what the critical care package includes. While CPR is separately reportable on critical care claims, the following services are bundled into critical care:

--Interpretation of cardiac output measurements (93561, 93562)

--Chest x-rays (71010, 71015, 71020)

--Blood gases (82800, 82803, 82805, 82810)

--Vascular access procedures (36000, 36410, 36415, 36540, 36600)

--Computer-stored patient data, such as ECGs, blood pressure readings, hematologic data (99090)

--Gastric intubation (43752, 91105)

--Ventilator management (94002-94004, 94660, 94662)

--Pulse oximetry (94760, 94761, 94762)

--Temporary transcutaneous pacing (92953).

Focus on Status and Time, Not Location

Although critical care is typically provided in certain settings (for instance, an emergency department or ICU), location shouldn’t drive your critical care coding, says Denae M. Merrill, CPC, coder for Covenant MSO in Saginaw, Mich. “Critical care can occur in an inpatient or outpatient setting as well as any location within the inpatient status,” she says. Conversely, the physician should not report critical care codes just because the patient is in a critical care unit.

What matters is the patient’s status. If the patient is critically ill or injured, and the physician spends at least 30 minutes on care services for the patient, you can use critical care codes.

Example: A pulmonologist is called to the medical/surgical unit to treat a patient developing pulmonary edema (428.1, Heart failure; left heart failure). The physician spends 104 minutes providing critical care services to the patient. On the claim, you should:

--report 99291 for the first 74 minutes of critical care service

--report +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) for the remaining 30 minutes of critical care service

--link 428.1 (Acute pulmonary edema) to 99291 and 99292 to prove medical necessity for the critical care.

Count More Than ‘Face Time’

One misconception about 99291 and 99292 is that the physician must be face-to-face with the patient, or he is not providing critical care. The physician can still give a patient critical care while not at the patient’s bedside, Bellm says.

Time spent with the individual patient is an integral part of critical care, but so is “time spent engaged in work directly related to the individual patient’s care, whether at the immediate bedside or elsewhere on the floor or unit,” she says.

Best bet: When adding critical care minutes, count any time “that the physician is engaged in work directly related to the patient’s care -- reviewing the patient’s chart, ordering tests, discussion with medical staff, etc., as long as these services occur on the patient’s unit/floor,” Bellm says. If the patient can’t participate in discussions, then time spent with family members or other decision-makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported in critical care time as well, she says -- as long as the conversation bears directly on the patient’s management.

Remember that the physician’s critical care service does not need to be continuous. According to CPT 2007, “critical care codes 99291 and 99292 are used to report the total duration of time a physician spends 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.” The key is documenting the time the physician spends with the critical care patient.

Suppose a pulmonologist provides 20 minutes of critical care to Patient A. He goes to another floor to check on Patient B for 15 minutes, then returns to Patient A to provide 30 more minutes of critical care. In this scenario, you can report 50 minutes of critical care time for Patient A as long as the documentation accurately reflects the encounter.

Check for Additional E/M Services

There are some instances in which you can report a critical care code and a separate E/M service code, says Rhonda Buckholtz, CPC, practice administrator at Wolf Creek Medical Associates in Oil City, Pa. “If other E/M services are provided to the patient on the same day that critical care is provided, you can report an E/M in addition to the critical care codes,” she says.

Merrill offers this example, in which a physician provides critical care and a separate E/M:

Example: During his morning rounds, the pulmonologist evaluates a patient who was hospitalized with breathing difficulty and performs subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...). In the afternoon, the physician gets an urgent call about the patient, who has suffered a respiratory arrest. The pulmonologist goes back to see the patient and provides 45 minutes of critical care. On this claim, you would:

--report 99291 for the critical care

--link 799.1 (Respiratory arrest) to 99291 to prove medical necessity for the critical care

--report 9923x for the hospital care

--attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 9923x to show that the critical care and E/M were separate services

--link 786.05 (Shortness of breath) to 9923x to represent the patient’s breathing difficulty.

Error averted: Do not separately bill for subsequent hospital care that a pulmonologist provides after critical care. Once a physician initiates critical care services for the day, you should not separately report any other E/M service.