Wiki PICU Coding Question

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mnmd9488

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Hi, I am not sure how to code the following situation.

Our PICU doc admitted pt from ED. We have a SOAP note for this encounter but it looks like the physician is combining the consultation note with the PICU day 1 note.

Pt was then seen multiple times next day and discharged.


I have read about some guidelines that we can bill 99291 for the initial consultation in ED and include the note "Services rendered prior to transferring patient to PICU" . But I am having trouble with how/when to apply this for patients
 
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How old is your patient because 99291 applies to ages 6 years and up who are in an inpatient or outpatient setting. There are critical care codes for neonates (through 28 days) 99468-99469, 29 days through 24 months 99471-99472 and 2 through 5 years 99475-99476 who are in an inpatient setting. For neonates and pediatric patients in an outpatient setting then you would use 99291-99292.

If your provider rendered all of the services included in 99291, to the patient while in the ED then it would be appropriate to bill these codes for the critical care services provided to the child in the ED as it is considered an outpatient setting. Then once the child is admitted to the PICU, the E&M services would then be coded based on what type of E&M services were provided to the child in the PICU.

It is crucial that you are billing the correct POS codes for the critical care services in the ED and then the E&M services provided in the PICU.
 
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The Day 1 PICU note would get coded with 99471. Pt was 49 days old at that time.

My issue is the dr is combining the consultation given in the ED and the actual H&P for Day 1 in the PICU. I don't know which to code, the consultation or the H&P.

These are the guidelines that I have. According to this regardless of age we can use 99291 for consultations prior to being admitted to PICU. We would have to note that the services were rendered prior to admission to picu.

Critical Care and Initial Neonatal and Pediatric Intensive Care Codes Providers may bill critical care codes (99291 or 99292) for services rendered before the child is admitted to the NICU/PICU when the global NICU/PICU codes 99222, 99223, 99468, 99471, 99475, 99477 are not billed by the same provider, for the same recipient and date of service. Provider’s billing code 99291 or 99292 may be reimbursed for services rendered to infants and children prior to the transfer to a PICU even if the global NICU/PICU codes are billed by another provider for the same date of service. Enter in the Remarks field (Box 80)/Additional Claim Information field (Box 19) of the claim that the service was rendered prior to transferring the recipient to a NICU or PICU. Note: Claims billed with codes 99232, 99233, 99291 and 99292 with modifiers TG and/or HA, 99469, 99472, 99476, 99478 thru 99480 (neonatal and pediatric intensive care) or Z3012 (extracorporeal membrane oxygenation) will not be reimbursed if critical care code 99291 or 99292 has been previously paid to any provider on the same date of service. Also, claims billed with critical care code 99291 or 99292 will not be reimbursed if codes 99232, 99233, 99291 and 99292 with modifiers TG and/or HA, 99469, 99472, 99476, 99478 thru 99480 or Z3012 have been previously paid to any provider for the same date of service.
 

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I think your last response is indicating the H&P happened on day 1 in the PICU, which you are billing 99471 for, is that correct? How could the provider treat the patient in the ED without an H&P if the patient was receiving critical care services as billed with 99291? You keep referring to a consult being done in the ED but referencing 99291 which is critical care, so was the patient receiving critical care services in the ED or truly a consult which would be represented by 99242-99245?

If the provider was providing critical care services in the ED and billing 99291 is appropriate, and the note needs to absolutely indicate that all services covered/bundled into 99291 need to be documented as having been done in the ED prior to admission to the PICU. Additionally, since 99291 (first 30-74 minutes) is a timed code and the minimum 30 minutes must be met to bill this code. The provider needs to document the exact amount of time (to the minute) was spent on providing the critical care services for the patient in the prior to the PICU admission. If the provider exceeded the 74-minute threshold and provided at least another 30 minutes of critical care services to the patient in the ED then the provider could also bill the add-on code 99292, but you must meet the 30-minute minimum to bill this code. A lot of providers are not detailed enough on exactly what critical care services were performed and exactly how much time was spent providing these services and the claims are denied due to the providers due to the lack of documentation for 99291-99292.

Once the patient was admitted to the PICU if the patient continued to receive critical care services as described by 99471, then you should be able to bill it in addition to the code(s) billed for the critical care services provided in the ED.
 
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Our PICU doc was called for a consultation to see if pt was a candidate for PICU. This note that our PICU doc wrote shows that he saw pt in the ED and spent 40 mins in critical care and consultation. We do NOT have a "Day 1" note for the PICU after this note only a follow up and a discharge.

It seems that the Dr is using this note that I am reading as an ED consultation note and a Day 1 PICU note. I know that I cannot code both the consultation and Day 1 using the same note, I am just unsure which to bill for with the documented information.

Here are some excerpts from the SOAP note I am reading.

Location: ED
History of Present Illness
Patient being admitted from the ED with the following history
Assessment/Plan:
Patient to be admitted to the PICU for close monitoring
Total time with patient and family is 40 minutes in critical care and consultation
 
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mnmd9488 said:
Our PICU doc was called for a consultation to see if pt was a candidate for PICU. This note that our PICU doc wrote shows that he saw pt in the ED and spent 40 mins in critical care and consultation. We do NOT have a "Day 1" note for the PICU after this note only a follow up and a discharge.

It seems that the Dr is using this note that I am reading as an ED consultation note and a Day 1 PICU note. I know that I cannot code both the consultation and Day 1 using the same note, I am just unsure which to bill for with the documented information.

Here are some excerpts from the SOAP note I am reading.

Location: ED
History of Present Illness
Patient being admitted from the ED with the following history
Assessment/Plan:
Patient to be admitted to the PICU for close monitoring
Total time with patient and family is 40 minutes in critical care and consultation
Click to expand...

So, if there is no documentation for the provider rendering services to the patient in the PICU on day 1 and your note only covers the time the patient was in the ED, then you would bill the services rendered while the patient was in the ED. I know you indicated that the info provided are excerpts from the SOAP note, but based on the fact that you are questioning the provider's documentation, I can't help but wonder what services were provided to the patient that meet the criteria of a critical care service and are they documented in the provider's documentation in the patient's medical record.

I'm not questioning your judgement/knowledge as a coder, but your initial post questioning how to code these services based on the way the provider documented the services provided on the first day of hospital care, which is what makes me question the provider's documentation.

I have worked in the insurance industry for 20+ years and critical care services billed with 99291-99292 are some of the most problematic claims because of the strict requirements for use of these codes and most specialist who are not critical care specialist struggle with the requirements of the code and making certain their documentation supports the use of the codes.

As I stated previously, in this post you can only bill for the services documented while the patient was in the ED since the provider did not provide services to the patient in the PICU on day 1.
 
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Thank you for the clarification! This particular situation is tricky and we are querying the PICU provider to see what was actually done besides seeing patient in the ED and deciding to admit the pt to the PICU.

I have not come across this situation before and I am struggling to find resources as to the requirements for consult notes, critical care notes, etc. I just know that something isn't right with the documentation as is.
 
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I don't know what type of coding software you use, or maybe you are using physical books. We use Optum's EncoderPro for Payers, and it has some really helpful features, like documentation tips, a layperson's description of the codes. Anyway, here is some info that may be helpful regarding 99291.

Critical care services are reported by a physician or other qualified health care provider for critically ill or injured patients. Critical illnesses or injuries are defined as those with impairment to one or more vital organ systems with an increased risk of rapid or imminent health deterioration. Critical care services require direct patient/provider involvement with highly complex decision making in order to evaluate, control, and support vital systems functions to treat one or more vital organ system failures and/or to avoid further decline of the patient's condition. Vital organ system failure includes, but is not limited to, failure of the central nervous, circulatory, or respiratory systems; kidneys; liver; shock; and other metabolic processes. Generally, critical care services necessitate the interpretation of many physiologic parameters and/or other applications of advanced technology as available in a critical care unit, pediatric intensive care unit, respiratory care unit, in an emergency facility, patient room or other hospital department; however, in emergent situations, critical care may be provided where these elements are not available. Critical care may be provided so long as the patient's condition continues to warrant the level of care according to the criteria described. These codes are time based codes, meaning the total time spent must be documented and includes direct patient care bedside or time spent on the patient's floor or unit (reviewing laboratory results or imaging studies and discussing the patient's care with medical staff, time spent with family members, caregivers, or other surrogate decision makers to gather information on the patient's medical history, reviewing the patient's condition or prognosis, and discussing various treatment options or limitations of treatment), as long as the clinician is immediately available and not providing services to any other patient during the same time period.​
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Time spent outside of the patient's unit or floor, including telephone calls, caregiver discussions, or time spent in actions that do not directly contribute to the patient's care rendered in the critical unit are not reported as critical care.​
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The following procedures are included/bundled into 99291, so the time spent on these procedures can be counted towards the critical care time, and these codes are not separately billable in addition to 99291.​
Professional services for interpretation:
Blood gases
Chest films (71045-71046)
Measurement cardiac output (93598)
Other computer stored information
Pulse oximetry (94760-94762)
Professional services:
Gastric intubation (43752-43753)
Transcutaneous pacing, temporary (92953)
Venous access, arterial puncture (36000, 36410, 36415, 36591, 36600)
Ventilation assistance and management, includes CPAP, CNP (94002-94004, 94660, 94662)
​
I don't know if this information helps you figure out if the documentation provided, or that may be provided as a result of your query to the provider, is sufficient to support billing 99291 or if you need to look at another E&M CPT code that better describes the services provided to the patient by your provider.
 
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