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The rules that govern critical care codes

Choose codes based on patients’ age and the amount of time you spend

August 2008

Published in the August 2008 issue of Today’s Hospitalist

MANY OF YOU TREAT PATIENTS who are critically ill or critically injured. But do you know that a special code set applies to patients with this type of high acuity?

Related article: Updated ICD-9 Codes for 2012-2013

In fact, CPT has one set of critical care codes that physicians should use when treating critically ill adults or children (24 months or older). There is another set of critical care codes for infants and toddlers, and still another for neonates.

While physicians often assume they can use critical care codes only for patients who are in an ICU, these codes are not specific to any particular area of a hospital or any specialty. They are instead based on patient acuity and duration of time for adults and children, and per-day occurrences for infants and neonates.

Here’s the rundown on critical care codes to help you get the right reimbursement for high-acuity services.

Critical care for adults and children
For patients age 24 months into adulthood, there are two critical care codes: 99291 and 99292.

Bill 99291 for critical care services that take between 30 and 74 minutes, then bill 99292 for every additional 30 minutes. If you spend less than 30 minutes on critical care services, use a regular, non-critical evaluation and management (E/M) service code based on history, exam and medical decision-making.
Make sure you note in the patient’s chart the total amount of critical care time spent on each code. You can count not only direct patient care, but the time you spend on activities like reviewing test results or imaging studies and discussing a patient’s care with other staff members.

If patients aren’t able to participate in discussions, you can also include time spent with the family or surrogate decision-makers obtaining history and reviewing the patient’s condition, prognosis and treatment.

Another key point: Critical care codes cover certain procedures as part of rendering critical care. When billing codes 99291 and 99292, for example, don’t separately report or bill for any of the following services:

  • interpretation of cardiac output measurement (93561, 93562);
  • chest X-rays (71010, 71015, 71020);
  • pulse oximetry (94760-94762);
  • blood gases;
  • gastric intubation (43752, 91105);
  • temporary transcutaneous pacing (92953);
  • ventilator management (94002-94004, 94660, 94662); and
  • vascular access procedures (36000, 36410, 36415, 36540, 36591, 36600).

Report and bill for any other CPT services that you provide and document appropriately. And remember to use one of two modifiers when documenting services that might appear to be covered by critical care codes.

Use the -25 modifier for a separately identifiable service “such as a lumbar puncture or a central line placement “performed on the same day as E/M services, usually with a 10-day or fewer global period. Use the -57 modifier for a decision to send a patient to surgery, usually for procedures that have a 90-day global period.

Critical care for infants and toddlers
When treating children between the ages of 29 days and 24 months, report CPT codes 99293 and 99294. Unlike the codes for older patients, these are per-day codes.

Use 99293 for the entire first day of initial care and stabilization. Bill each subsequent inpatient critical care day with 99294.

As with adults and children, the critical care codes for infants and toddlers automatically cover certain services. In addition to the services included in the list above, the following services are considered to be part of the pediatric critical care codes (and also part of the neonate critical care codes, which follow):

  • umbilical venous (36510) and umbilical arterial catheters (36660);
  • other arterial catheters (36140, 36620), and central (36555) or peripheral vessel catheterization (36000);
  • vascular access procedures (36400, 36405, 36406, 36420) and vascular punctures (36420, 36600);
  • endotracheal intubation (31500) and lumbar puncture (62270);
  • bladder aspiration (51100) and bladder catheterization (51701, 51702);
  • CPAP (94660) and surfactant administration (94610);
  • transfusion of blood components (36430, 36440); and
  • bedside pulmonary functioning test (94375).

Report any other separate services with an appropriate modifier.

Neonate critical care
For critical care delivered to children 28 days old or younger, use CPT codes 99295 and 99296. These are also per-day codes, so bill 99295 for the day of initial care and stabilization, then 99296 for each subsequent inpatient critical care day.

For neonates who need an intensive care setting but who are not critically ill, use the initial inpatient codes (99221-99223). Bill any subsequent visits with subsequent visit codes (99231-99233).

If a neonate is in a low birth rate range, however, use the following codes for subsequent visits:

  • 99298: subsequent intensive care, per day, for the evaluation and management of recovering birth weight (present body weight less than 1500 g);
  • 99299: subsequent intensive care, per day, for the evaluation and management of recovering birth weight (present body weight less than 1500-2500 g); or
  • 99300: subsequent intensive care, per day, for the evaluation and management of recovering birth weight (present body weight less than 2501-5000 g).

Due to the evolving age ranges, it is important to understand each critical care code set and its requirements. That’s the only way to maximize your critical care reimbursement.

tamaraTamra McLain is an independent coding consultant in Southern California who is available for in-house training for physicians and coders. E-mail her your documentation and coding questions to helpucode@yahoo.com. We’ll answer your questions in a future issue of Today’s Hospitalist.