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Critical Care and Prolonged Care Codes Address Intensity of Family Physician Services

Codes available to reimburse for special care and extend time provided to critically ill patients.

By Douglas J. Jorgensen, DO, CPC

Many doctors routinely take care of critically ill patients as part of their daily practices. In more rural settings and even in urban centers, the family physician may be the only one around when the patient begins a rapid clinical decline.

Often, hours are spent, office appointments rescheduled, and rounding on other patients are temporarily put off to manage the critically ill patient. The payors will pay for the time and expertise you provided their beneficiary, but only if you ask and appropriately code for it.

Other times, the patient is not really critically ill, but due to a family meeting to discuss end-of-life issues or placement post-hospitalization, hours are spent coordinating nursing, social services and other ancillary health care personnel to provide optimum care and comfort for your patients.

The patient may not in fact be critically ill, but the care needed to provide empathic, quality medical care cannot and should not be hurried into a brief visit on your daily hospital rounds. Prolonged care codes exist and in certain instances help to pay for your time, assuming certain criteria are met.

Critical Care Codes 99291 & 99292
Critical care codes are designed and intended for just that, critical care. These codes should be used for acute critical care of unstable patients due to a critical illness or injury.¹ They are used for constant care and supervision of critically ill patients.

Your patients need not be in the CCU or ICU setting as this is not always where patients are when they take a turn for the worse. Conversely, just because they are in the ICU or CCU does not mean the code is appropriate.

If you are not providing critical care for more than 30 minutes, then simply use the appropriate evaluation and management code, be it a consult (99251-99255) or inpatient subsequent hospital care (99231-99233).

Many coders and doctors believe that the consult or hospital visit can be coded or the critical cares used; not both. This is a misnomer. E&M codes and critical care codes are not mutually exclusive, and can and should be used simultaneously, where appropriate.^2,3

Exactly what is “critical care” is a definition left to the person caring for the patient. For uniformity, if you are in a group practice, all of your providers should meet to define what is and what is not “critical care.” Doing so will create more uniformity and will not make one of you an outlier potentially invoking the audit gods. Once established, this definition should become part of your compliance plan. Additionally you want to make sure you do not overuse this code.

If the patient is critically ill throughout the day and you must provide acute care at varying intervals, add up your time and submit the total time (See Figure 1). The 99291 is used for the first 30-74 minutes of the critical care and each 30 minutes thereafter is equal to one unit of the 99292 code.

A new 30-minute interval begins at the 15-minute mark. If the time is less than 15 minutes, then you do not get credit for additional time but revert back to the previous half hour interval. However, if you are at over even slightly over 15 minutes, a new half hour unit may be billed via the 99292. By using clock time (9:05-10:10, 13:00-13:25, 17:45-19:12) you add up the total minutes and bill the 99291 x 1 then the 99292 x 4 in addition to your E&M services for the day.^4,5

Table 2 reviews codes that are bundled or part of the critical care payment. Do not bill for these services separately.⁶ If you provide a service that is not on this list, then bill for it separately. However, the time performing this service should not be billed as part of the critical care time as it is being billed separately.⁷ The only exception to this is the E&M service for the day that should be billed based on the history, physical, medical decision making, etc. Again, the E&M service can be billed in addition to the critical care codes.

Used appropriately, critical care codes can help optimize reimbursement in-house that many physicians are losing in their offices due to canceling appointments for emergencies. Some national trends show physicians undercoding out of fear of retribution. Do not literally throw money away out of fear. Code correctly and bill appropriately for your services, and you will see the results of your hard work in your reimbursement.

Prolonged Care Codes
Prolonged service codes are used when patient care exceeds the routine amount of time. This service is reported in addition to routine services (i.e.: E&M) and can be face-to-face (direct patient contact 99354-99357) or not face-to-face (99358-99359) such as a family meeting. The –21 modifier is also supposed to pay for prolonged care, but in fact it is often denied by payors so codes 99354, 99355, 99356, 99357, 99358 and 99359 are recommended instead.⁸

Sometimes, when patients are seen, they may be given a diagnosis that needs a lengthy explanation or discussion of treatment options. As such, the time element on the E&M codes is only partly helpful. Once the time element is exceeded another means to be reimbursed for one’s time is needed. Prolonged services must exceed 30 minutes in order to be billed.^9,10

A similar time methodology, like the critical care codes’ system, is used here except that the physician must exceed, by 30 minutes, the threshold time of the E&M visit. Therefore, if 30 minutes or more is not spent over and above the time assigned to the E&M service billed, you should not bill prolonged care codes.¹¹ Critical care carries a different burden of proof for the patient may be critically ill throughout the care you are providing and thus the E&M code should be billed in addition to critical care time if appropriate.

Codes 99354 and 99356 are used to report the first hour of prolonged care in the outpatient and inpatient settings, respectively. Each additional 30-minute increment (which commences 15 minutes after the last unit ended) is billed by using 99355 and 99357 for outpatient and inpatient settings, respectively.¹²

Remember the outpatient settings could be office, nursing facility, emergency department and/or observation (in the hospital or ER) settings. Inpatient means admitted to the inpatient service at the hospital. Codes 99358 and 99359 can be used in the inpatient or outpatient setting. 99358 is for the first hour and 99359 is for each additional half hour.¹³ Medicare will not pay for 99358 or 99359 codes and thus private payors may follow their lead.¹⁴

Like the critical care codes these codes should not be abused. Furthermore, one must be cautious that the time being billed for prolonged care is just the time being used for the family meeting or in the care of the patient and not time for other calls or unrelated business.

The total time in a 24-hour period is again cumulative and should be added up using clock time and is per doctor (not cumulative for a group of doctors). Therefore, the codes 99354, 99356 and 99358 should not be used but once per day. The subsequent time should be billed with the units system with their respective counterpart codes.

Summary
Prolonged care and critical care codes can optimize reimbursement and allow you to spend the time you need with your patients. Make sure not to use them because you are rounding slowly or for a partner who is habitually behind in the schedule. This would be most inappropriate and could have a deleterious outcome.

Not all payors will pay these without question, especially if you have not been using them consistently or at all. Therefore, expect some letters and calls and perhaps even requests for documentation. However, if you follow the rules and apply these codes judiciously, you will see some reimbursement for time most doctors thought was just part of good doctoring that simply paid via intangible means.

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Douglas J. Jorgensen, DO, CPC is a family physician with Manchester Osteopathic Healthcare in Manchester, Maine. He is a Certified Professional Coder and founder of Jorgensen Consulting, a national professional services organization offering educational forums and coding consultation. He can be contacted via e-mail at ems@ctel.net.

References
1. Gordy, T.R. Ed.; Current Procedural Terminology 2001; American Medical Association, Chicago, p. 19, 2000.
2. Ibid
3. Medicare Carrier Manual Section 15508 C.
4. Gordy, T.R. Ed.; Current Procedural Terminology 2001; American Medical Association, Chicago, p. 20, 2000.
5. Medicare Carrier Manual Section 15508 F.
6. Medicare Carrier Manual Section 15508 D.
7. Ibid
8 Gordy, T.R. Ed.; Current Procedural Terminology 2001; American Medical Association, Chicago, p. 26, 2000.
9. Medicare Carrier Manual Section 15511 C.
10. Ibid
11. Medicare Carrier Manual Section 15511 G.1.
12. Medicare Carrier Manual Section 15511 E.
13. Gordy, T.R. Ed.; Current Procedural Terminology 2001; American Medical Association, Chicago, p. 27, 2000.
14. Medicare Carrier Manual Section 15511.2

  
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Table 3

 

Figure 1