Prolonged and Critical Care Codes

1. Prolonged and Critical Care Codes When to bill and what needs to be documented…..

2. Prolonged Care – When?CPT Codes 99354-99357 • Used when time of required patient care exceeds normal time guidelines for E/M codes by at least 30 minutes. • Cannot bill second code if <15minutes left after billing for first hour or if <15 minutes left beyond the last 30 minute charge. • Time DOES NOT have to be continuous.

3. Prolonged Codes-Correct E/M • Prolonged care services ARE NOT payable unless they are accompanied by the E/M companion codes. • E/M is chosen based on level of exam, then the prolonged code is calculated. • Can be used on any level E/M, does not have to be the highest code UNLESS you are billing based on time alone!!! • MUST document total time spent with patient • Do not be general, “> 1 hr spent with patient”, be specific, “I spent 65 minutes with patient”

4. What Codes to Use and Documentation • Can be used with Inpatient/Outpatient, initial/established patients, consults/follow ups.

5. Standard Times for Outpatient Visits:

6. Standard Times for IP Visits:

7. Critical Care Codes: 99291-99292 • Definition: Direct delivery of medical care for a critically ill or injured patient. • Acutely impairs one or more vital organ systems, high probability of imminent or life threatening deterioration • Encompasses treatment of “vital organ failure” and “prevention of further life threatening deterioration…” • i.e) CNS failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. • Patient must be critically ill at time of service but does NOT have to be in ICU.

8. Correctly Using Critical Care Codes • Can include all time spent evaluating, providing and managing patient’s care, as long as physician is immediatelyavailable to patient. • Physician must devote FULL attention to patient and cannot provide services to any other patient during that time. • Physician’s of same specialty and group are billed as one provider. • Time does not have to be continuous. • Does NOT get reported with an E/M code, unless patient was seen earlier in the day and was not critical at that time!!!!

9. Included in Critical Care Codes: These Procedures ARE included: • the interpretation of cardiac output measurements (CPT 93561, 93562) • pulse oximetry (CPT 94760, 94761, 94762) • chest x-rays (CPT 71010, 71015, 71020) • blood gases • information data stored in computers (CPT 99090) • gastric intubation (CPT 43752, 91105) • transcutaneous pacing (CPT 92953) • ventilator management (CPT 94656, 94657, 94660, 94662) • vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600)

10. What is NOT included in codes: • CPR – 92950 • Endotracheal Intubation – 31500 • Central Line – 36556 • Cannot include time spent on procedure in calculation for total critical care time. • Cannot include time spent teaching or time spent by the resident in absence of TP.

11. Documenting Critical Care • Physician may refer to resident’s dictation for specific history, findings, and medical assessment • Physician documentation MUST include: • Time spent providing critical care excluding any time spent on separately reported procedures • Statement that patient was critically ill during the time the patient was seen • What made the patient critically ill • Nature of the treatment and management provided

12. How to Use Critical Care Codes Now let’s look at some examples!!!!

13. Critical Care Example: • Hospitalist A sees the patient on admission, and spends 40 minutes of critical care time with the patient. That evening, hospitalist B from the same group, that is covering, sees the patient for an 35 minutes of critical care. What codes would get billed? • A) Each hospitalist would bill 99291 for their initial critical care. • B) Hospitalist A would bill 99291 and hospitalist B would bill for follow-up, 99233. • C) Hospitalist A would bill 99291 and hospitalist B would bill 99292. Answer: C

14. Questions????? Jeni Smith, CPC(352) 733-0217j.smith@ufl.edu