Coding Strategy

If patient’s critical care and visit satisfies time regs, 99291 is the better bet.

When scouring the notes for evidence of an emergency department caveat scenario, coders can easily forget to ask themselves one simple question: Can I report a critical care code for this scenario?

The answer’s yes more often than you might think, says Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La.

“Many patients who qualify for the caveat may also be candidates for critical care. If the condition is severe enough that the patient’s ability to provide this information is impaired, then the condition may be critical,” she explains.

Critical Care Omits Specific History Component

Considering critical care and the caveat simultaneously can make your head spin, as the ED caveat does not even apply to 99291 (Critical care, evaluation and management of the critical ill or critically injured patient; first 30-74 minutes) or +99292 (… each additional 30 minutes [List separately in addition to code for primary service]).

Why? “There are not the same bullet-counting requirements for documentation of history, physical examination, or MDM [medical decision making] for critical care,” explains Edelberg. The descriptors for critical care concern only E/M of the critically ill or injured patient.

So when your physician invokes the emergency department caveat for a patient, check to see if the patient was critically ill or injured; if she was, and the physician documents at least 30 minutes of critical care, consider 99291.

Payout: The only level of service you can invoke the emergency department caveat on is 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity …).

The 99285 code pays about $171 nationally (4.74 transitioned facility relative value units [RVUs] multiplied by the temporary 2010 Medicare conversion rate of 36.0846), whereas 99291 garners about $217 (5.99 RVUs multiplied by 36.0846).

Check Out This Critical Caveat Scenario

We asked Michael Lemanski MD, emergency department billing director at Baystate Medical Center in Springfield, Mass., to describe a scenario in which the physician provides critical care to a patient who also qualifies for the emergency department caveat:

Emergency medical services (EMS) presents with two teenage girls that were involved in a high-speed motor vehicle crash with roll-over. One of the girls has been extricated, has a traumatic amputation of her left arm, and lost vital signs en route to the ED. The other has a head injury, is hypotensive, and appears too intoxicated to provide any history for either patient. The girl who lost vitals en route is clearly critically injured, but the only history available to the physician is when the collision occurred, where, and how. Details about past medical history, social history, family history and review of systems (ROS) are unavailable. The physician spends a total of 64 minutes providing critical care services for the patient.

Caveat achieved, but …: In this instance, the emergency department physician could reasonably invoke the emergency department caveat — but it is unnecessary, as you should report 99291 for this encounter.

@ Emergency Department Coding Alert (Editor: Chris Boucher, CPC).

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From head to toe, the new diagnosis codes hold something for everyone.

Whether your patients present with cardiologic, orthopedic, or gynecologic complaints, the next round of ICD-9 codes could hold important changes for you. Here’s the rundown on the new codes most relevant to radiologists — including a new option for retained magnetic metal fragments.

Remember: ICD-9 2011 will go into effect Oct. 1, 2010. The official version will be released in the fall, so the codes below are not yet final.

1. Look Forward to More Specific Ectasia Codes

The proposed changes to ICD-9 2011 add four codes specific to aortic ectasia. These codes are among the most significant changes for radiology coders because you may see that term in your radiologist’s findings, says Helen L. Avery, CPC, CHC, CPC-I, manager of revenue cycle services for Los Angeles-based Sinaiko Healthcare Consulting Inc. “Ectasia” means dilation or enlargement, and aortic ectasia typically refers to enlargement that is milder than an aneurysm. But ICD-9 2010 does not distinguish ectasia from aneurysm, indexing aortic ectasia to 441.9 (Aortic aneurysm of unspecified site without mention of rupture) and 441.5 (Aortic aneurysm of unspecified site, ruptured).

The proposed 2011 codes are specific to aortic ectasia and differ based on anatomic site:

• 447.70 — Aortic ectasia, unspecified site
• 447.71 — Thoracic aortic ectasia
• 447.72 — Abdominal aortic ectasia
• 447.73 — Thoracoabdominal aortic ectasia.

2. Watch for ‘Claudication’ in Stenosis Report

Another one of the important changes is the proposed addition of 724.03 (Spinal stenosis, lumbar region, with neurogenic claudication), says Avery. The code refers to lumbar spinal stenosis, which is a narrowing of the spinal canal, according to the Sept. 16-17, 2009, ICD-9-CM Coordination and Maintenance Committee meeting proposal (available here). Neurogenic claudication “is a commonly used term for a syndrome associated with significant lumbar spinal stenosis leading to compression of the cauda equina (lumbar nerves),” the proposal states.

ICD-9 2010 includes 724.02 (Spinal stenosis, other than cervical; lumbar region). Andelle Teng, MD, a spine and orthopedic surgeon in Washington, requested a code addition to differentiate patients with and without neurogenic claudication because “with” is a possible surgical condition. The 2011 proposal revises 724.02 to “Spinal stenosis, lumbar region, without neurogenic claudication,” in contrast to the 724.03 proposal for patients with claudication.

3. Match New Uterine Codes to Clinical Class

If you code gynecological imaging, don’t miss the proposed new codes for uterine abnormalities. So-called müllerian duct abnormalities can cause infertility, but surgical correction is sometimes possible. Radiological imaging, usually MRI, confirms the diagnosis, so the radiologist should document the specific type of abnormality in his findings, Avery says. The ICD-9 2011 proposal expands the 752.3 (Other anomalies of uterus) range:

• 752.31 — Agenesis of uterus
• 752.32 — Hypoplasia of uterus
• 752.33 — Unicornuate uterus
• 752.34 — Bicornuate uterus
• 752.35 — Septate uterus
• 752.36 — Arcuate uterus
• 752.39 — Other anomalies of uterus.

Bonus tool: Avery reveals how the ICD-9 2011 proposal matches to the müllerian duct abnormality classifications:

Watch for: You’ll also find proposed expansion of 752.4x (Anomalies of cervix, vagina, and external female genitalia):

• 752.43 — Cervical agenesis
• 752.44 — Cervical duplication
• 752.45 — Vaginal agenesis
• 752.46 — Transverse vaginal septum
• 752.47 — Longitudinal vaginal septum.

4. Review New Retained Fragment Proposals

Over one-third of the proposed codes are “V” codes, which describe “supplementary classification of factors influencing health status and contact with health services,” according to the ICD-9 manual. A number of the codes describe retained fragments, which the radiologist may note in his findings, Avery says.

For instance: For retained metal fragments, you would choose among the following:

• V90.10 — Retained metal fragments, unspecified
• V90.11 — Retained magnetic metal fragments
• V90.12 — Retained nonmagnetic metal fragments.

The Department of Defense requested codes to help identify retained objects resulting from explosion injuries, but the codes could prove useful in other cases, as well. For example, an embedded magnetic object (V90.11) is a contraindication to an MRI exam.

Resource: CMS posted the proposed codes as part of the Inpatient Proposed Payment System, available online here. To review the codes, download “Proposed Tables 6A-6K.” Table 6A includes proposed new codes, 6C shows the proposed deletions, and 6E lists proposed revisions.

@ Radiology Coding Alert (Editor: Deborah Dorton, JD, MA, CPC).

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If you performed a consult in 2006, the auditor will use 2006 guidelines — not today’s rules.

Most Part B practices have grown accustomed to tucking consult regulations into the backs of their minds, since Medicare no longer pays for these services. However, if an auditor comes calling and wants to review your consult notes, he will be judging you based on the Medicare rules as of the date of service.

Some practices assume that any audits taking place in 2010 or thereafter that involve consult notes will be based on CPT consult rules, and not Medicare’s, since Medicare does not recognize consult payment as of 2010. Because Medicare’s consult regulations were generally more strict than CPT’s, practices consider this a small victory. But this is inaccurate, experts say.

“If the auditor is reviewing services you performed in 2009, CMS rules from 2009 will apply,” confirms Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC with CRN Healthcare Solutions in Tinton Falls, N.J.  “In 2006, Medicare changed the rules — so if they audited 2005 consult services, it would be a different standard than 2009 services as well,” she says.

Requests for Notes May Follow

The Medicare auditor may not just want to read your physician’s notes, but may even request notes from other practitioners if it’s necessary to back up your claims.

“In evaluating consults, I have even experienced one audit where they also requested the referring physician’s documentation to substantiate the reason for the consult,” says Devona Slater, CHC, CMCP, president and compliance auditor with Auditing for Compliance and Education Inc. in Leawood, Kan.

“Medicare’s definition of a consult and the CPT definition have always been different and a reason for confusion,” Slater says.
Slater says she has seen auditors who find that practices don’t have adequate consult documentation “downcode the consults to new or established patient visits and request a refund for the difference.”

Get the latest provider news by subscribing to the Part B Insider. Editor: Torrey Kim, CPC

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Use these FAQs to achieve level 5.

A patient reports to the emergency department in such severe respiratory distress that she cannot communicate during the history of present illness (HPI) portion of the E/M service. The patient also presents to the ED alone via ambulance, meaning there was no one else to speak for her.

How can a coder decide on the history level for this ED E/M service? Knowing an important exception to the HPI rules in ED settings will help you accurately report these incidents.

When a physician documents that an HPI [history of present illness] is unobtainable due to patient condition, you can invoke the caveat, explains Lori Bettencourt, CPC, PCS, coder at Pro-Medbill LLC in Hampton N.H.

Benefit: The ED caveat can prevent E/M downcoding based on the E/M HPI component. Follow this FAQ to get the lowdown on all the ED caveat rules you’ll need to code correctly each time.

What Are the Caveat Basics?

“In real life, ED physicians are not always able to obtain a complete history from a patient. Of course the physician should always document any history they can obtain from the patient, family or friends, EMS, nursing home, etc.,” says Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass. If the history is limited, however, the caveat “allowsthe physician to receive ’full-credit’ for even a comprehensive history – if you document why the history could not be obtained,” Lemanski stresses.

“The caveat is a CPT exception unique to emergency medicine 99285 services. It provides an exception to the E/M content requirements when the physician is unable to obtain the required [history] information,” relays Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La. This could be due to the urgency of the patient’s condition or the physician’s mental status.

For instance: The ED physician performs a comprehensive exam and high-complexity medical decision making for a patient, but she cannot get enough information from the patient for a comprehensive history. If you invoke the ED caveat in this instance, you might be able to report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity …).

How About a Clinical Example?

Consider this potential ED caveat scenario, courtesy of Edelberg:

A 64-year-old patient presents to the ED with altered mental status and left-sided facial droop. The physician examines the patient, but the patient cannot provide any useful history information. The physician orders a CT scan of the head, the patient is admitted to rule out a stroke. Notes indicate that the physician performed a comprehensive exam and high MDM.

In this scenario, you might be able to invoke the ED caveat if the physician documented her inability to obtain a full history, and report 99285 for the encounter.

How Can I Spot Potential Caveat Claims?

In a perfect world, the physician would stamp “ED caveat” on each relevant claim, but coders will have to be good spotters to make the caveat work for them.

How? Coders might be able to identify caveat situations based on terms the physician uses, says Bettencourt. Some terms that could indicate a caveat if they appear in the notes include:

• history unobtainable
• history obtained by family member due to altered mental status.

Other possible keys: Lemanski offers these terms that might indicate a patient that is unable to fully communicate:

• unresponsive
• obtunded
• comatose
• aphasic
• paralyzed and intubated
• incoherent due to intoxication or drugs.

How Do I Document the Caveat Situation?

In order to submit a successful caveat claim, however, you need to include two specific pieces of information. Find out what they are by subscribing to the ED Coding Alert.

Editor: Chris Boucher, CPC

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Beware: CPT, CMS differ on ‘family discussion’ parameters.

When the physician treats a patient with a critical illness or injury, you need to know when to start and stop the critical care clock in order to avoid miscoding. Check out this FAQ to find out what’s part of critical care, what’s not, and how to correctly count the minutes to ensure the most accurate and profitable 99291-+99292 claims.

Q. What Must I Carve Out of Critical Care Time?

Be careful when considering critical care minutes; many services that you might think are part of the 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) package are actually separately billable procedures, pointed out Caral Edelberg, CPC, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La., during her recent presentation on ED trauma coding at The Coding Institute’s multi-specialty conference in Orlando, Fla.

“The critical care clock stops,” explains Edelberg, during separately billable procedures such as CPR; endotrachael intubation; chest tube/central line insertion; ultrasound interpretation; and laceration/orthopedic repairs.

Critical care time also excludes the following:

• teaching time aside from the actual care

• most time spent speaking with authorities, family members, or caregivers that do not directly bear on the patient’s medical care (There are exceptions to this rule; check FAQ 2 for more info).

Also, don’t just use total time the patient spends in the ED, because not all of it is active critical care time.

Example: The physician provides uninterrupted treatment of a critically ill patient for a total of 84 minutes. During that time, he performs CPR for eight minutes, spends three minutes teaching, and discusses the patient’s condition with family members for five minutes.

In this instance, the physician provided 68 minutes of critical care (84 ” 8 ” 3 ” 5 = 68), which you’d report with 99291.

Q. What’s Included in Critical Care Time?

Most other services that the physician provides to the critically ill patient are part of the 99291 package. This bundle of services includes: interpretation of cardiac output measurements, x-rays, pulse oximetry, blood gasses, and information data stored in computers (such as ECGs, blood pressures, and hematologic data); gastric intubation; temporary transcutaneous pacing; ventilatory management; and vascular access procedures (though not most central line codes).

‘Discussion’ exception: Though most interactions with authorities, family members, or caregivers are typically not part of critical care time, there are exceptions, points out Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

“[Critical care] time does not include time speaking with family/authorities — unless obtaining history or discussing advanced directive matters,” Edelberg noted.

CPT and Medicare have specific commentary regarding what types of circumstances and conversations outside of direct patient care may count toward critical care time:

Medicare rules: The interactions are part of critical care when “the patient is unable or incompetent to participate in giving a history or making treatment decisions, and the discussion is necessary for determining treatment decisions,” Contreras says.

CPT rules: CPT states that when the patient is unable or clinically incompetent to participate in discussions, time spent on the floor or in the unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the medical decision making.

If you have any questions about either of these “discussion” exceptions, be sure to clear things up with the payer before deciding what interactions can count toward critical care.

Q. What Is the Minute Minimum for 99291-+99292?

From Medicare Transmittal 1548, July 9, 2008: “The CPT code 99291 is used to report the first 30-74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient by the same physician or physician group of the same specialty.

“CPT code +99292 [... each additional 30 minutes ...] is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care. Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E/M code.”

CPT rules: “The language in CPT requires 75-104 minutes for base service (99291) and one segment of +99292,” says Edelberg. This means that strictly by CPT definition, you can use +99292 to report even one minute of critical care past 74.

Cautionary note: Though Medicare references the above CPT table in several recent Medicare transmittals, some experts are concerned about reporting critical care of less than 15 minutes beyond the initial 74 with +99292. Be sure to check with your payer if you are unclear on its policy.

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