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I BILLING AND CODING I How to get paid for your services I By Carol Pohlig, BSN, RN, CPC, ACS

Report Critical Care


Critical care is a time-based service. It constitutes the physician's time spent providing direct care at the bedside and gathering and reviewing data on the patient's unit or floor. If the physician is not immediately available to the patient, the time associated with indirect care (e.g., reviewing data, calling the family from the office) is not counted in the overall critical-care service. The physician keeps tracks of his/her total critical-care time throughout the day. A new period For more in-depth information about of critical-care time begins billing for your services, attend the each calendar day. There is precourse "Fundamentals of Inpatient no prohibition against Coding and Documentation: Getting reporting multiple hours or Paid What You Deserve" from 8 a.m.-5 days of critical care, as long p.m. April 3 at SHM's Annual Meeting as the patient's condition in San Diego. prompts the service and documentation supports it. Code 99291 represents the first Condition and Care "hour" of critical care, which physicians A patient's condition must meet the may report after accumulating the first established criteria before the service 30 minutes of care. Alternately, physiqualifies as critical care. More specificalcian management of the patient involvly, the patient must have a critical illness ing less than 30 minutes of critical-care or injury that acutely impairs one or time on a given day must be reported more vital organ systems such that there with the appropriate evaluation and is a high probability of imminent or lifemanagement (E/M) code: threatening deterioration in the patient's T Initial inpatient service (99221condition. 99223); The physician's personal attention T Subsequent hospital care (99231(i.e., care involving one critically ill 99233); or patient at a time) is essential for renderT Inpatient consultation (99251ing the highly complex decisions neces99255). ospitalists often encounter patients who are or could become critically ill. The increased efforts while caring for these patients are best captured through critical-care service codes 99291 and 99292. Although these codes yield higher reimbursement ($204.15 and $102.45, respectively, per national Medicare average payment), they are reported only under certain circumstances. The physician's documentation must include enough detail to support critical-care claims: the patient's condition, the nature of the physician's care, and the time spent rendering care. Documentation of any other pertinent information is strongly encouraged because these services often come under payer scrutiny. sary to prevent the patient's decline if left untreated. Given the seriousness of the patient's condition, the physician is expected to focus only on the patient for whom critical-care time is reported.

Strict guidelines and case detail must support these time-based codes



99291: Critical care, evaluation, and management of the critically ill or critically injured patient; first 30-74 minutes. 99292: Critical care, evaluation, and management of the critically ill or critically injured patient; each additional list 30 minutes separately in addition to code for primary service. Code 99291 is used to report the first 30-74 minutes of critical care on a given date. It should be used only once per date even if the time spent by the physician is not continuous on that date. Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E/M code. Code 99292 is used to report additional blocks of time, of up to 30 minutes each beyond the first 74 minutes.



Once the physician achieves 75 minutes of critical-care time, he/she reports 99292 for the additional "30 minutes" of care beyond the first hour. Never report 99292 alone on the claim form. Code 99292 is considered an "add-on" code, which means it must be reported in addition to a primary code. Code 99291 is always the primary code (reported once per physician/group per day) for critical-care services. Code 99292 can be reported in multiple units per physician/group per day according to the number of minutes spent after the initial hour (see Table 1, p. 30).

Service Inclusions

Critical care involves highly complex decision making to manage the patient's condition. This includes the physician's performance and/or interpretation of labs, diagnostic studies, and procedures inherent in critical care. Therefore, do not report the following services when billing 9929199292: T Cardiac output measurements (93561, 93562);

T Chest X-rays (71010, 71015, 71020); T Pulse oximetry (94760, 94761, 94762); and T Blood gases (multiple codes). Further, don't report interpretation of data stored in computers: T Electrocardiograms, blood pressures, hematologic data (99090); T Gastric intubation (43752, 91105); T Temporary transcutaneous pacing (92953); T Ventilation management (94002-94004, 94660, 94662); and T Vascular access procedures (36000, 36410, 36415, 36591, 36600). Any other service or procedure provided by the physician can be billed in addition to 99291-99292. Be sure not to add separately billable procedure time into the physician's total critical-care time. A notation in the medical record should reflect this (e.g., time spent inserting a central line is not included in today's critical-care time).

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CASE 1 (family meetings): The hospitalist provides 45

minutes of critical care to a patient admitted with septicemia. The patient's condition worsens despite multiple efforts, and the patient's family arrives later in the day to discuss the patient's condition. The discussion lasts an additional 30 minutes, and the decision regarding the patient's do not resuscitate status is made. What service(s) should the hospitalist report?


Family meeting time can be counted toward critical-care service time when: T The patient is unable or clinically incompetent to participate in discussions; T Time is spent on the unit/floor with family members or surrogate decision makers obtaining a medical history, reviewing the patient's condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care; T The conversation bears directly on the management

of the patient. Meetings that take place for grief counseling involving the patient's family (90846, 90847, 90849) are not reported separately or included as part of the critical-care time. This scenario meets the criteria for inclusion in critical-care time. A total of 75 minutes was spent for the day. The hospitalist can report one unit of 99291 and one unit of 99292. Note: A common physician-reporting error for the scenario above involves reporting 99291 with a prolonged care (99356-99357) or subsequent hospital care codes (99231-99233). Prolonged care is reserved for use with initial hospital care (99221-99223), subsequent hospital care (99231-99233), and inpatient consultation codes (99251-99255). Reporting subsequent hospital care codes for the family meeting is also erroneous since the patient had received critical care for the day. As per Medicare guidelines, both critical care and an E/M service can be paid (appending modifier 25 to the E/M: 99291, 99233-25), but only if the inpatient E/M service was furnished early in the day when the patient did not require critical care, yet required it later that same day. Documentation must sup-

port this situation because it will need to be sent to the insurer before payment is obtained. Once critical care is initiated, subsequent evaluations on the same day are counted toward critical-care time, as in this scenario.

CASE 2 (multiple physicians): The hospitalist sees the

patient upon admission to the ICU, spending and documenting 40 minutes of critical-care time. That evening, the covering physician (a hospitalist from the same group practice) renders 35 minutes of critical care. Can each hospitalist submit a claim for 99291?


No. Only one physician per group practice (same specialty) can report 99291 per day. The additional time is captured with 99292. Because 99292 must be reported as an add-on code with 99291 (i.e., cannot be reported by itself on a claim), submit one claim representing the culmination of all critical-care services provided by the group for the day. Select one physician's name (typically the physician who initiated critical care), and report one unit of 99291 with one unit of 99292 for the 75 minutes of critical care provided.



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Because a patient can become seriously ill in any setting, physicians often provide critical-care services in emergency departments (EDs) and on standard medical-surgical floors before the patient is transferred to the intensive care unit (ICU). Bed location alone does not determine critical-care reporting. Patients assigned to an ICU might be critically ill or injured and meet the "condition" requirements for 99291-99292. However, the care provided may not meet the remaining requirements. According to the American Medical Association's Current Procedural Table 1. Critical Care Codes Total Duration of Critical Care Less than 30 minutes 30-74 minutes 75-104 minutes 105-134 minutes 135-164 minutes 165-194 minutes 194 minutes or more

Terminology 2008 (Professional Edition) and the Medicare Claims Processing Manual, payment can be made for critical-care services provided in any location as long as the care provided meets the definition of critical care. Services for a patient who is not critically ill and unstable but who happens to be receiving care in a critical-care, intensive-care, or other specialized-care unit are reported using subsequent hospital care codes 99231-99233 or hospital consultation codes 99251-99255. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM's inpatient coding course.

Codes Appropriate E/M codes 99291 x 1 99291 x 1 and 99292 x 1 99291 x 1 and 99292 x 2 99291 x 1 and 99292 x 3 99291 x 1 and 99292 x 4 99291 and 99292 as appropriate

Source: American Medical Association, Centers for Medicare and Medicaid Services



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