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Does your claim include a provider statement?

Patients who report to the emergency department (ED) for critical care services are in peril; they need immediate medical intervention or things could go very badly for them 鈥� and fast.

That鈥檚 one of the reasons 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) is a high-value code: 8.21 nonfacility relative value units (RVUs). Its closest ED evaluation and management (E/M) code comparison is 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making), which offers 5.22 nonfacility RVUs.

Caveat: In order to rightfully report 99291 and +99292 (鈥� each additional 30 minutes (List separately in addition to code for primary service)), you need to check several boxes based on information from the encounter form. Take this advice on critical care coding so you can make the right decisions on each claim you see.

Make Sure Patient Is Critically Ill

CPT^庐 states that a patient must be critically ill or injured in order to use critical care codes. It is important to know what this means, as your coding will depend on whether the patient was critically ill or injured.

Critically ill or injured implies that there is a risk of loss of life/loss of function (or further loss of function) of a major organ and/or organ system, with an acute or exacerbated presentation of the condition.

Though there are hundreds of diagnoses that a critical care patient might have, patients who are critically ill or injured often suffer from an illness or injury in one of these general areas:

• Respiratory failure
• Cardiovascular emergency
• Neurological emergency
• Severe infection
• Trauma
• Surgical complications
• Organ failure
• Poisoning or overdose
• Life-threatening allergic reactions

Look for Level of MDM, Encounter Time

The successful reporting of critical care codes requires you to scour the notes for information on several encounter elements.

First, the ED physician must perform high-complexity medical decision making (MDM), which includes assessment, manipulation, and support of vital system functions. The physician must also describe what made the MDM high complexity by documenting the following:

• Assessment of the historical details and physical status relating to the patient鈥檚 current condition, pertinent risk factors, and general history, physical examination and health factors that contribute to the critical problem
• The methods utilized by the treating provider during the critical care course used to stabilize the patient鈥檚 critical and unstable condition and manipulate and support the patient鈥檚 condition 
• Written confirmation of at least 30 minutes of constant attention by the billing physician 

Check for at Least 30 Minutes of Critical Care

As mentioned in the above section, the physician must provide at least 30 minutes of constant attention to a critically ill or injured patient in order to report 99291. Even if the patient is critically ill or injured, less than 30 minutes of critical care time means you鈥檒l have to report the appropriate ED E/M code. A provider must devote full attention to the patient during time spent providing critical care and cannot provide services to any other patient during the exact same time counted toward critical care time.

The critical care time, however, does not need to be continuous 鈥� as long as a total of 30 minutes caring exclusively for the critically ill/injured patient is tallied. The time doesn鈥檛 necessarily have to be spent at the patient鈥檚 bedside, either. This time may include time spent engaged in work directly related to the patient鈥檚 care. However, time spent in activities outside of the floor, unit, or ED may not be reported as critical care since the provider is not immediately available to the patient.

Identify Separately Billable Services

Your ED physician might perform separately billable services during a critical care session. CPT^庐 reports that the following services, however, 鈥渁re included in in critical care when performed during the critical period by the physician(s) providing critical care:

• 鈥淭he interpretation of cardiac output measurements (93598),
• 鈥淐hest X rays (71045, 71046),
• 鈥淧ulse oximetry (94760, 94761, 94762),
• 鈥淏lood gases, and collection and interpretation of physiologic data (eg, ECGs, blood pressures, hematologic data);
• 鈥淕astric intubation (43752, 43753);
• Temporary transcutaneous pacing (92953);
• Ventilatory management (94002-94004, 94660, 94662); and
• Vascular access procedures (36000, 36410, 36415, 36591, 36600).鈥�

When reporting critical care, CPT^庐 informs coders that 鈥淎ny services not included in this listing should be reported separately.鈥�

Remember Provider Statement

It is the responsibility of the provider to document the time spent providing critical care to a critically ill or injured patient. The provider must also indicate that critical care time does not include separately billable services. Some practices won鈥檛 even bill critical care without a provider time statement. Instead, they assign the appropriate ED E/M code, which will be costly if the only thing keeping you from reporting 99291 is a provider statement.

Example: A patient has a total encounter time of 55 minutes: 35 minutes in critical care and another 15 minutes receiving cardiopulmonary resuscitation (CPR). The ED physician would include a provider statement to the effect of: 鈥淐ritical care time 35 minutes. CC time does not include time spent performing CPR.鈥�

Chris Boucher, MS, CPC, Senior Development Editor, AAPC