Urology Coding Alert

Question: In the afternoon, our urologist saw a patient for 30 minutes on the hospital floor, during which time she provided level-two subsequent hospital visit/care. That evening, she transferred the patient to the intensive care unit. There, the physician provided 60 minutes of critical care for the patient. How should I code this? The urologist says there should be more than one code because of the extra time and work provided, but I'm not so sure. Who's right?


Delaware Subscriber


Answer: Your physician is right. You should report a pair of codes -- as long as you can prove the urologist provided critical care services during the second care session.

On the claim you should:

• Report 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) for the subsequent hospital visit/care. Remember that some carriers will require that you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to this service to indicate that this was a hospital visit earlier on the same day.

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

Heads-up: Before you bill for critical care, make sure you know that 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, according to the Medicare Carriers Manual.

Your physician should provide decision-making of high complexity to assess, manipulate, and support circulatory, respiratory, central nervous, metabolic or other vital system function to prevent or treat single or multiple vital organ system failure.

Typically, physicians administer critical care in a "critical care area," such as the emergency department or intensive care unit. But Medicare (and possibly private carriers) will pay for critical care that a doctor provides in any location as long you meet CPT and Medicare guidelines. And remember, just because the patient is in an intensive care or critical care unit doesn't mean you can automatically report 99291.

You should report services for a patient who is not critically ill and unstable ¾ but who happens to be in a critical care, intensive care or other specialized care unit ¾ using subsequent hospital care codes (99231-99233) or inpatient consultation codes (99251-99255). And for a physician to bill critical care, she must devote her full attention to the patient and cannot render any E/M services to any other patient during the same period of time.