Health Information Management

Q/A: Critical care coding

APCs Insider, June 19, 2009

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Q: My question pertains to critical care provided in an ER at a Level 1 Trauma Center. If a patient  receives at least 30 minutes of trauma care (minus time spent on procedures) we can bill CPT code 99291 for professional services. May we also bill 99291 on the facility side for nursing care. I have received conflicting information about billing in this situation—that we may bill only CPT code 99285 for the facility side and that 99291 is for professional services only. Please clarify.
 
A: Your facility may bill critical care with 99291 also for at least 30 minutes of face-to-face critical care. This calculation includes time spent by the physician and hospital staff providing critical care. Note, however, that participation by multiple physicians or staff members does not increase the amount of time. If you provide fewer than 30 minutes of critical care, report the E/M codes for the ER. If you provide more than 74 minutes, you may use CPT add-on code 99292 for additional 30-minute increments. Note that 99292 has an “N” status indicator and is packaged for payment purposes, so the additional increments of time will not yield additional payment.  
 
Hospitals can verify whether they should bill certain HCPCS codes, such as 99291, by referring to Addendum B under the OPPS system for the status indicator Q3 is the status indicator for 99291, indicating separate payment when composite APC criteria are not met and payment as part of a composite when they are met. Critical care has a Q3 status indicator because it may also be part of the Level II Extended Assessment and Management Composite if you provide observation with the critical care. Proper processing of payment for the Extended Assessment and Management Composite when critical care is provided requires billing the code along with the observation services on the same claim.
 
An additional charge for either a full or modified trauma response/activation fee billed under revenue code 068X with G0390 is appropriate for facilities approved as trauma centers when a field activated trauma response occurs. Coding critical care correctly is essential for proper claims processing. Trauma activation code (G0390) will not process if the critical care code does not appear on the same claim. Trauma activation is a separate, significant payment ($935.12 unadjusted for CY2009) for trauma response activation before the trauma patient arrives at a Level I-IV trauma center. 
 
 CMS has clarified its position that hospitals must follow the bundling guidelines outlined in the CPT manual, which considers certain procedures, such as chest x-rays,  part of critical care. Therefore, billing such procedures in addition to critical care is inappropriate. In this case, do not subtract the time spent performing the procedure because it is included in the time spent providing critical care and is billed as part of the critical care, not separately.



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