Pulmonology Coding Alert

Question: Are there rules stating my physician must have a certain amount of history of present illness (HPI) and review of systems (ROS) to bill critical care time? Our internist documented a physical examination and that he spent 30 minutes with the patient. Can I report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)? Florida Subscriber Answer: No, you do not need all the elements of the patient's HPI and ROS to report critical care codes when the physician has documented critical care time. Critical care isn't based on any of the data elements associated with E/M levels -- it's based on time for the critically ill or critically injured patient and the highly complex nature of the service. Critical care is defined as the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A [...]