Published in the November 2009 issue of Today’s Hospitalist
ACCORDING TO THE 2009 TODAY’S HOSPITALIST Compensation & Career Survey, more than 70% of hospitalists serve in some capacity in the ICU. That means that hospitalists are making great use of critical care codes. But would your critical care documentation hold up to the scrutiny of an audit?
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Critical care codes are reimbursed at a substantially higher rate than those for acute care, so you need to make sure you reap your well-deserved reimbursement for the critical care services you provide. But deciding how to bill for those services can be tricky because critical care codes are time-based.
Let’s take a look at how critical care is defined and at what you can bill in terms of time.
Supporting critical care codes
Critical care is defined as physicians’ direct delivery of medical care for a critically ill or critically injured patient. A critical illness acutely impairs one or more vital organ systems, which means that a patient’s condition has a high probability of imminent or life-threatening deterioration.
According to CPT guidelines, critical care services include both treatment of “vital organ failure” and “prevention of further life threatening deterioration of the patient’s condition.” Your critical care documentation should stand apart from your admission documentation or progress notes, and it should support the medical necessity for critical care. Some key elements to document include:
- interventions taken to keep the patient from imminent or life-threatening deterioration;
- the high complexity of your decision-making and thought processes that kept the patient from either deteriorating or deteriorating further;
- specifics of what was done to support vital system functions or to address organ failure, including assessing labs, medical tests or X-rays.
What can you count as time?
You can bill one or both of two critical care codes:
- 99291: critical care, evaluation & management, first 30- 74 minutes;
- 99292: critical care, each additional 30 minutes.
But figuring out what you can include toward your total amount of critical care time can be tough.
First, the critical care time you bill can include only time that is devoted solely to that patient. The time does not have to be continuous, but it can’t include time not directly involved with that patient’s care.
Time spent in the following activities counts toward total critical care time:
- time spent at the bedside with the patient;time spent on activities that contribute to the patient’s care, such as reviewing old records and lab and imaging results, and consulting with other physicians; and
- time spent with family, whether to obtain a history or to discuss treatment options when a patient is not able to participate.
When your critical care time includes discussions with family or caregivers, make sure you document that the time you are billing pertained to the direct treatment of the patient.
Procedures count too
There are services often performed during critical care that you can’t bill separately. However, the time spent performing these services counts toward your total critical care time. Those services include:
- gastric intubation (43752, 91105);
- interpretation of blood gases and interpretation of data stored in computers, such as ECGs, blood pressure, hematologic data (99090);
- interpretation of cardiac output (93561-93562);
- interpretation of chest X-rays (71010-71020);
- pulse oximetry (94760-94762);
- temporary transcutaneous pacing (92953);
- vascular access procedures (36000, 36410, 36415, 36591, 36600); and
- ventilator management (94002-94004, 94660, 94662).
Any other services that aren’t on this list “such as placing central lines or chest tubes, doing endotracheal intubations, and performing CPR “may be billed separately. The time you spend performing these other services, however, can’t be included in your total critical care time. Be sure to document that the critical care time you’re billing does not include the performance of a separately billable service or procedure.
The 30-minute issue
Then there’s this question: How much of “each additional 30 minutes” must you perform to be able to bill a 99292? CPT guidelines state that you need to spend at least 75 minutes to report both 99291 (for initial critical care) and 99292 for the additional 30 minutes.
However, there is some controversy about reporting code 99292 when the amount of time you spend beyond the initial 74 minutes is less than 15 minutes. Check with your carriers, but when billing Medicare, I recommend using the more conservative approach and billing 99292 only if you have performed 15 minutes beyond the initial 74-minute time frame. Also remember that CPT code 99292 should be reported in addition to 99291 when billing for that additional time.
As for critical care services that take less than 30 total minutes, you’re at a disadvantage because you cannot bill them using a critical care code. Instead, bill such services with an acute care evaluation and management (E/M) code.
Keep in mind that Medicare does allow you to bill both critical care codes and an inpatient hospital service performed on the same day, if the patient becomes critical after the inpatient hospital care has been rendered.
Finally, if you do not document the total time spent providing critical care, your record will not support the use of critical care codes. In such cases, your bill may be denied or downcoded to an acute care E/M code.
Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at email@example.com. We’ll try to answer your questions in a future issue of Today’s Hospitalist.