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Provider Alert - Vol. 2 - How to Use Critical Care Codes (99291-99292) and (99281-99285)

How to use Critical Care codes (99291-99292)

Critical Care is defined as an 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 and that the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition.

This underused code set requires physician documentation of the time spent directly managing the unstable or potentially unstable patient. Time spent documenting, reviewing labs and radiographs, and speaking with medical staff also counts towards total critical care time. Time spent on separately billable procedures, like CPR (92950), doesn't. You must have provided at least 30 minutes of services to bill, and the "first hour" of critical care includes the first 74, not 60, minutes. Additional time increments over the initial 74 minutes are billed with 99292 for each additional 15-30 minute segment. Time must be clearly documented by the provider and does not need to be continuous.

Part 2 - Critical Care codes

While there are codes you may use in addition to critical care (99291 and 99292), CPT bundles certain separately identifiable services into the codes for critical care. The bundled codes are included in the list below:

  • the interpretation of cardiac output measurements (CPT 93561, 93562)

  • chest x-rays (CPT 71010, 71015, 71020)

  • pulse oximetry (CPT 94760, 94761, 94762)

  • blood gases, and information data stored in computers (CPT 99090)

  • gastric intubation (CPT 43752, 91105)

  • temporary transcutaneous pacing (CPT 92953)

  • ventilatory management (CPT 94656, 94657, 94660, 94662)

  • vascular access procedures (CPT 36000, 36410, 36415, 36540, 36600), these are peripheral access. Central access is not bundled.

Any procedures not on this list can be billed separately, and the time spent performing additionally billed procedures must be deducted from Critical Care time and indicated in the record. A statement such as "Critical care time spent in direct management of this patient was 75 minutes exclusive of separately billed procedures" it is recommended.

Emergency Department After-Hours Code

Tired of working night shifts? There is a code is available to report services provided in the ED after10 pm. Patients presenting to the ED between10 pm and 8 am may have code 99053 (After-Hours code) reported in addition to the standard 99281-99285 for emergency department levels of service. This code is not typically paid by governmental payers, but can result in modest additional payments from others.

Level 5 Caveat

The definition of 99285 includes the concept that the History, Physical Exam, and Medical Decision Making (key requirements) must be met "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status". This concept is called the emergency medicine caveat or the acuity caveat. Although the Medical Decision Making is referenced as one of the elements, the general consensus is that the caveat would apply to the History and Physical Examination.

Most Medicare carriers require a description of the patient's urgent condition that prevents obtaining any of these key elements of the Evaluation and Management service as well as the physician's thought process through the discussion of risk factors, differential diagnoses, procedures, diagnostic studies, interventions and disposition. So make sure to document why the severity of your patient's illness and/or procedures such as intubation on arrival preclude or prevent performing a full History or Exam.

In House Codes

Don’t lose revenue for inpatient codes, consults, critical care and emergent procedures. Establish a procedure to alert coding/billing staff for inpatient emergent services, ensure they can locate the inpatient encounter, and take the time to document your services. If the inpatient attending requested your expertise to assess a patient, be sure an official consult order is noted in the chart. Also note--consults require 3/3 past medical/family/social history elements for high acuity patients. Document total time spent during the patient encounter.


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