Health Information Management

Understand the rules for reporting critical care codes

JustCoding News: Outpatient, June 16, 2010

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

Medical coding for any department requires a keen eye to detail and a partnership between coders and physicians. Due to the varying nature of patients’ conditions and the fast-paced environment, ED coding challenges approach the apex of coding complexities.

ED coders must understand coding guidelines for both physician billing and facility billing because they often bill for both, including evaluation and management (E/M) critical care codes. During HCPro’s April 26 audio conference “Emergency Department Facility and Professional Coding: Ensure Complete Documentation and Accurate Charge CaptureJoanne M. Becker, RHIT, CCS, CCS-P, CPC, CPC-I, associate director in the Joint Office for Compliance at the University of Iowa Hospitals and Clinics in Iowa City and Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associations in Baton Rouge, LA, discussed the numerous difficulties and solutions related to critical care ED coding.

Although there are only two critical care codes, coders may still find it challenging to assign these codes because they must first understand how to count critical care time and also know which services are included when reporting critical care and which services providers may report separately.

Count face-to-face time only once

Consider the two critical care codes, which are time-based, for the E/M services provided to critically ill and critically injured patients—99291 and 99292.

Time capture obviously plays a vital role in selecting the appropriate code(s), so refer to the helpful chart included in the Critical Care Services section in your 2010 CPT Manual to assign the appropriate code(s) for total duration of care.

When calculating critical care time, you should only include the time a physician and/or hospital staff spends engaged in administering face-to-face care, Becker emphasized during the audio conference. However, you can only count time once, even though multiple staff members, including a physician, may be simultaneously engaged in the active face-to-face care (e.g., physicians and nurses working with the same critical care patient), Becker said.

Recognizing overlapping time between physicians and other hospital staff is crucial when assigning critical care codes, Becker said. Because these are time-based codes, documentation and legibility are particularly crucial considering how one minute can change reimbursement, Becker said.

For professional coding of critical care, ED physicians may count the time they spend documenting, interpreting diagnostic studies, and communicating with staff, family, and/or care givers.

And remember, when billing for other procedures, subtract the time the clinician spends performing them from the critical care time you are billing, Edelberg said.

Recognize bundled services

Becker posed the following common critical care inquiry: “What services are included in CPT code 99291 and should therefore not be billed separately?” Always turn to the CPT guidelines, which state that hospitals should not separately bill services that CPT guidelines indicate are included in the reporting of code 99291.

Becker notes that despite what some may call CMS’ strict interpretation of the CPT exclusions, CMS maintains that “providers must apply the E/M physician guidelines to hospitals when reporting services in conjunction with critical care,” said Becker.

The following services are bundled for code 99291:

  • Interpretation of cardiac output measurements
  • Chest x-rays
  • Pulse oximetry
  • Blood gases and data stored in computers
  • Gastric intubation
  • Temporary transcutaneous pacing
  • Ventilatory management
  • Vascular access procedures

Note that you may separately bill the services listed above only when clinicians provide them after the critical care period, Becker said.

Distinguish facility and physician coding

It’s important to distinguish between physician and facility coding, Edelberg said. Physicians follow the CPT guidelines or Medicare’s 1995 Documentation Guidelines for Evaluation & Management Services or 1997 Documentation Guidelines for Evaluation & Management Services, Edelberg said. Facility coding, however, requires hospitals to use their own acuity-based guidelines to support reporting codes 99291 and 99292. So although facilities and physicians use the same codes, the reporting requirements can vary.

For example, a facility may code for critical care for a particular claim when the staff appropriately document the time spent providing those services. The physician must also document the time he or she spent providing critical care, according to the physician reporting requirements. When an ED physician forgets to document that time, coders can’t bill that critical care for the physician, Edelberg said.

Physicians, nurses, and other ED providers need to document detailed orders and operative notes, discharge instructions, and any additional ED services, Edelberg said. Coders need this information to assign appropriate codes and receive appropriate reimbursement and to support the claim in the event of an audit, Edelberg said.

Due to the differences in counting time, sometimes facilities meet the criteria for reporting critical care but physicians don’t.

Report add-on code 99292 when appropriate regardless of reimbursement

Becker emphasized that it’s important to report add-on code 99292 when appropriate even though a particular service is considered packaged. “Just because there is no separate facility reimbursement for [code 99292], that doesn’t mean we should not report it,” Becker said. The code provides claims data that is valuable for future rate setting, Becker added.

Coders can code ED services, which include critical care, even when the physician does not see the patient, according to Becker. The outpatient prospective payment system (OPPS) tiptoes around whether it is permissible to bill an ED visit code, but OPPS never specifies the type of hospital staff required to provide the services, Becker said.

So even though a physician was not necessarily present, you can bill these as incident-to services. For professional coding for Medicare, don’t count the time for services provided by anyone other than the ED physician for whom you are billing. For example, time spent by physician extenders and residents working under ED physician supervision doesn’t count. Other payers may have unique rules governing shared services, so check with your individual payers.

Editor’s note: Please visit HCPro’s Healthcare Marketplace to learn more about the audio conference, “Emergency Department Facility and Professional Coding.” E-mail questions to Joanne M. Becker, RHIT, CCS, CCS-P, CPC, CPC-I, at E-mail questions to Caral Edelberg, CPC, CPMA, CCS-P, CHC, at

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular