Coding for physician inpatient services, especially critical care, is deceptively straightforward. The reality is that the details of each code requirement can complicate things to the point of complete confusion.
Despite the challenges, there are specific strategies you can use to correctly identify when critical care codes are supported, says coding and reimbursement consultant Kim Garner-Huey in her live audio conference with ProfEdOnDemand. Instead of focusing on where the treatment took place, you’ll need to know how much time was spent with the patient, as well as whether or not the service provided would fall under the definition of critical care.
During her presentation on appropriate coding and billing for inpatient services, Huey discusses how to differentiate key details in critical care codes, as well as how to optimize documentation and confidently appeal rejected claims.
Not Just for Emergency Rooms
CPT® defines critical care as “a physician’s direct delivery of medical care for a critically ill or critically injured patient.” The care “involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.” Further, a critical illness is defined as one that “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”
It’s important to remember type of care provided is more important than location when it comes to critical care coding. Providing care to a stable patient in ICU, for example, would not count as critical care, while providing treatment for a life-threatening situation outside of a critical care area would.
Keep Track of Time with 99291 and 99292
If the terms for critical care are met, the next important factor in determining how to properly code is the time spent caring for the patient.
The main codes for critical care, 99291 and 99292, describe the amount of time spent caring for the patient, not the services provided. If less than 30 minutes was spent on critical care, then you must use the appropriate evaluation and management (E/M) service code. For 30-74 minutes spent, you would use code 99291.
If, instead, the amount of time spent in critical care was between 75 and 104 minutes, then you would code in the following way: 99291 x 1 (e.g., 1 unit) and 99292 x 1 (e.g., 1 unit). After 104 minutes, you would keep on with the following 30-minute-increment pattern, as outlined by the Centers for Medicare & Medicaid Services (CMS):
- 105-134 minutes: 99291 x 1, 99292 x 2
- 135-164 minutes: 99291 x 1, 99292 x 3
- 165-194 minutes: 99291 x 1, 99292 x 4, and so forth.
When using these codes, it’s vital to remember that CMS and CPT® handle critical care codes slightly differently, as outlined by compliance experts at CodingIntel. When billing, it’s crucial you check with the payer – be it Medicare, Medicaid, or a private payer – regarding their rules on critical care coding and reimbursement. Be sure to check as well if the payer requires or prohibits the addition of any modifier (such as -25) when submitting the claim.
Document, Document, Document
The importance of proper documentation in successful physician inpatient billing cannot be overstated. When it comes to critical care coding, documentation must show the following, according to coding experts at ICD10monitor:
- The amount of time the patient spent with the patient
- The medical necessity of the service provided
- Which organ system was at risk
- The rationale behind providing the service, and which procedures were performed
- All critical findings from tests
- The patient’s response to the treatment
- The patient’s plan of care
Cooperation is Key
With all the factors to consider, billing for critical care can be one of the most difficult areas of internal medicine. Providers must be as specific as possible, and coders should always go back to physicians with any gaps in the patient’s record. This partnership is key to successful billing and physician coding, says Huey, and will greatly increase your chances of getting maximum reimbursement the first time around.