Coding Update

Coding for critical care: Timing is everything

[Editor's note: With this issue, we begin a quarterly column on coding in the ED by Caral Edelberg, president of Edelberg Compliance Associates. If there are coding issues you would like to see addressed in this column, contact: Caral Edelberg, CPC, CCS-P, CHC, Edelberg Compliance Associates, Baton Rouge, LA. Phone: (225) 454-0154. EFAX Number: (225) 612-6904.]

Documentation and billing for ED critical care continue to present a challenge for hospitals. The rules are based somewhat on Current Procedural Terminology (CPT), but with a twist added by the Centers for Medicare & Medicaid Services (CMS). The rules differ enough from the professional rules to create a challenge for ED providers and coding professionals. Becoming conversant with the various impacts that time has on different CPT codes will go a long way toward overcoming that challenge.

As of Jan. 1, 2007, hospital critical care services have been paid at two levels, depending on whether there was also trauma activation. Hospitals receive one payment rate for critical care without trauma activation, and they receive an additional payment when critical care is associated with trauma activation and billed accordingly. When critical care services are provided without trauma activation, the hospital may bill CPT code 99291, Critical Care, Evaluation and Management (E&M) of the Critically Ill or Critically Injured Patient; First 30-74 Minutes. If critical care time is documented longer than 74 minutes, 99292 Critical Care would be billed for each additional 30 minutes of critical care. If trauma activation occurs under the circumstances described by the National Uniform Billing Committee (NUBC) guidelines that would permit reporting a charge, the hospital also may bill one unit of trauma activation code G0390, which describes trauma activation associated with hospital critical care services.

Time, intensity, and content of the service form the foundation of critical care, which is often considered the sixth E&M level. Critical care is defined as a critical illness or injury 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. Key to understanding appropriate billing of critical care is an understanding of how a routine E&M service makes the jump to critical care. As the CPT guidelines indicate, hospitals that provide less than 30 minutes of critical care should bill for a visit, typically an ED visit, at a level consistent with their own internal guidelines. Critical care requires 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. Examples of vital organ system failure include, but are not limited to, central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.

The time spent managing the critical patient is the key factor. For the hospital to bill the facility component of this service, documentation must support a minimum of 30 minutes of critical care service to the patient. Medicare Pub 100-94 MCP (Medicare Claims Processing), Transmittal 1139, Dec. 22, 2006, has stated this 30-minute minimum has always applied under the outpatient prospective payment system (OPPS) and will continue to apply. CMS says under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or injured patient.

If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can be counted only once. Thus, to ensure this service is coded correctly, documentation clearly must state the start and stop times spent with the patient by each health care provider, so that coding professionals can accurately count individual and group provider times accurately. Although time in excess of 74 minutes can be billed, the 2008 ambulatory payment classification (APC) payment for 99291 Critical Care includes payment for additional time billed with the 99292 code, so don't expect the extra payment — although at some point in the future when CMS has an opportunity to review all of the critical care utilization data, it's possible the agency might assign a separate payment to this charge.

Often, critical patients require life-saving interventions in the ED. One of the most frequent is cardiopulmonary resuscitation (CPR). The levels of critical care are determined by time. When CPT code 92950 is reported, the time required to perform CPR is not included in critical care, according to the Correct Coding Initiatives (CCI) edits. CPR CPT 92950 is payable under APC 0094 as a type S procedure. CPR and any additional procedures provided by ED staff or consultants supported by ED staff are separately billable by the hospital as long as the time spent performing these procedures is removed from the time used to determine critical care.