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Pulmonology Coding Alert

Resuscitate Critical Care Payment:

Educate Physicians

Published on Sun Jun 01, 2003

Insufficient physician documentation not your coding skills could be jeopardizing reimbursement for your critical care claims.

Tell your doctors about the payment they sacrifice if they don't understand when and how to document critical care, says James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa. and then help them out with the information below.

'High Probability' Opens Reimbursement Doors

Critical care may cover more services than you or your physicians think it does.

Critical care services include the direct delivery of medical care to a critically ill or injured patient, says Deborah Grider, CPC, CPC-H, CCS-P, CCP, president of Medical Professionals Inc. in Indianapolis. A critical care patient must have the "high probability of imminent or life-threatening deterioration," according to CPT.

But don't overlook the phrase "high probability" that's what could increase your revenue. A patient doesn't have to be on her deathbed to require these services. The necessary condition is the risk for, not the presence of, instability. "Physicians so often fail to document critical care time on patients whose condition could deteriorate rapidly into a life-threatening situation," says Nettie McFarland, RHIT, CCS-P, at Healthcare Billing Systems Inc. in South Daytona, Fla.

Here's an example of when your pulmonologist provides critical care services, reported 99291 ( first 30-74 minutes) and +99292 ( each additional 30 minutes), for a patient who never technically becomes unstable. The physician provides care for the patient with a severe allergic reaction who has hives and is wheezing. The patient then develops stridor (786.1) but does not have respiratory failure, although the imminent potential is very real.

In this case, the presenting problem not the final diagnosis or condition determines the risk factor of the case. The severe allergic reaction presents the potential for an unstable, high-risk condition, so diagnosing and treating the crisis warrants critical care codes. Note, however, that almost all allergic reactions would not qualify as critical care because in most cases the physician only has to administer an antihistamine and maybe a breathing treatment.

Here's a useful rule of thumb for determining critical care status. For you to report critical care, the patient must be on a medication or a treatment regime that is supporting an organ system, and without that treatment the patient would be unstable, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. This approach will keep you from over-reporting critical care.

Watch Your Documentation

Documentation is the saving grace of critical care payment. Review your documentation completely before using it to support critical care codes, McFarland says.

Check that documentation covers the site of service, medical necessity and services provided, Grider says. Payers are looking for appropriate risk factors, progress and response to treatment, whether it's positive or negative, she adds.

Tell your physician to document:

  • The high-complexity decision-making. Reporting critical care requires this component as indicated by CPT's definition of this service.

  • Revisions of diagnosis. For example, when a patient with respiratory failure improves the next day but "still requires ventilation," your physician should document this change in condition and append appropriate documentation, e.g., for vent settings, she says.

  • Critical care time. Your physicians must document time spent rendering critical care on the chart and then date and sign the documentation. This documentation requirement is crucial because reimbursement for critical care codes depends on time spent by the physician providing care. If the physician doesn't document properly (see below for guidelines on adequate documentation), send the chart back to him and ask him to return it within a reasonable time, for example four to five days, Blakeman says.

    Documentation can show either the total duration of time or indications of start and stop times, Grider says. Beware, however, that some carriers have issued transmittals requiring that physicians use start and stop times, she adds, so check your local carrier's policy.

    Here are pointers on how to accurately total critical care time:

    1. Tell your physician to subtract from the critical care time any additional time he spends on:

  • separately reportable procedures and services. Critical care does not cover time spent on these additional services, Grider says.

  • activities that don't directly contribute to the patient's care, including meetings, and time spent consoling the family, unless that conversation brings up points relevant to the patient's care, Blakeman says.

    The patient must be unable or incompetent to participate in providing information or discussing treatment if the physician counts time with family members or decision-makers toward critical care, Grider adds. And you cannot count any time spent on the telephone with the family as critical care, she says.

    2. Refer to the CPT time chart for reporting time spent. The minimum time requirement for critical care codes is 30 minutes. When a patient requires fewer than 30 minutes of critical care, you should report the physician's services using an E/M code and include the documented critical care services when assigning the E/M code, Blakeman says. Documentation of the need and use of critical care will demonstrate the risk involved in the E/M case. This may be helpful for supporting your E/M level but is not required for reporting other hospital care services (99221-99233).

    3. Report 99291 only once per date even if the physician's time spent is not continuous. Critical care time does not have to be consecutive, but it can be cumulative on a given date of service. Physicians should add together interspersed critical time periods and report the sum.

     

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