Published in the February 2011 issue of Today’s Hospitalist
When billing, do I have to state when the services are for critical care? Or can I use more general language, such as "direct care," with a critical care code (99291-99292)?
I’d recommend that you avoid such general wording as "direct care" because it could be interpreted many ways. That phrase also doesn’t indicate the amount of time that you spent providing critical care, and that’s important.
When billing critical care, I’d suggest using this type of statement: "I have spent 40 minutes on critical care services, minus any separately billable procedures." Let me explain why you should include this caveat statement, which could be valuable in terms of reimbursement.
According to CPT guidelines, some procedures are bundled into the critical care codes (99291-99292). Those include the following:
● Cardiac output measurements (93561, 93562)
● Chest X-rays (71010, 71015, 71020)
● Pulse oximetry (94760, 94761, 94762)
● Blood gases, and information data stored in computers (99090)
● Gastric intubation (43752, 91105)
● Temporary transcutaneous pacing (92953)
● Ventilator management (94002-94004, 94660, 94662)
● Vascular access procedures (36000, 36410, 36415, 36594, 36600)
Aside from the procedures on this list, anything else you do outside the total amount of time being reported for critical care services can also be coded and billed. Remember, the sum total for critical care has to be 30 minutes or more, or you can’t bill for any critical care services. Instead, you have to use regular evaluation and management (E&M) service codes.
Some procedures that are often performed in life-threatening situations are CPR (92950), endotracheal intubation (31500), lumbar puncture (62270) and central venous lines (codes vary depending on the patient’s age and the approach used). Make sure that your critical care time is distinct from the procedure code. And remember to use the modifier -25 (affixed to the E&M code) to indicate a significant, separately identifiable procedure on the same date as an E&M service by the same physician.
Two doctors, one discharge
Please clarify how we should bill the following scenario: Hospitalist A (or a physician assistant) dictates a full discharge summary on the day before the patient is discharged. At the end of her dictation for that day, hospitalist A states, "Total time spent with this discharge took more than 30 minutes." Hospitalist A then bills a 99232 subsequent care visit.
Hospitalist B comes in the next day and dictates a short addendum to the previous day’s discharge summary. (Sometimes, however, he or she doesn’t need to do an addendum so does only a handwritten progress note.) Hospitalist B then bills a 99239 (high-level discharge), as if he or she has done the full discharge summary.
The majority of the work for the discharge was done the day before. Is it OK for hospitalist B to bill a 99239? Or should we bill his or her time on the day of discharge as an appropriate level subsequent care visit?
The key thing here is to remember that hospitalist A has to essentially perform two distinct sets of services.
The first is the subsequent hospital visit (99231- 99233), and she needs to base that level of service on meeting or exceeding guideline requirements in two of the three areas: history, exam and medical decision-making. Once that service is complete, I don’t see any problem with hospitalist A then launching into what’s needed for the next day’s discharge.
In fact, I think this is an acceptable and quite typical practice nationwide for many groups. But you want to make sure that the two services don’t overlap and that hospitalist A keeps each separate from the other.
Also, only one physician can get credit for the discharge because both doctors are part of the same group and billing under the same tax identification number, so they are operating as one entity. I’d recommend that you include among your group’s compliance policies a written statement that explains how group members are going to contribute to discharge planning and which hospitalist will get billing credit for the discharge service.
I suggest that hospitalist B should be the individual capturing the total duration of discharge service time. It strikes me as a little presumptuous for the first hospitalist involved to assume that the discharge is going to take more than 30 minutes.
Then there’s this possible twist: Hospitalist B may see the patient on the date the discharge is supposed to take place, but the patient doesn’t get released. That may be the result of abnormal test results or some other kind of complication. Hospitalist B would then disregard the discharge services code and report the appropriate level of subsequent hospital visit (99231-99233).
Tamra McLain is client services manager with MedData Inc. E-mail her your documentation and coding questions at firstname.lastname@example.org. We’ll answer your questions in a future issue of Today’s Hospitalist.