In this issue:
Coding News
Are Your Missing Opportunities to Bill Critical Care?
By Candace E. Shaeffer, RN, MBA, RHIA
Vice President, Coding Operations/Quality Management
Ongoing audits, ED visit level frequency distributions and documentation feedback indicate that many ED physicians are documenting less critical care than their patients’ acuity supports. From a clinical perspective, ED physicians frequently perform “critical care services.” However, in order to code and bill for Critical Care, 99291, the documentation of the patient’s condition and treatment must meet CPT and payer requirements. In our experience, physicians and payers sometimes have a different functional definition of critical care. The information below is intended to help narrow this gap. Sufficient documentation for a critical care encounter will help ensure that LYNX coders can code the record to the 99291 level it deserves.
The following is a summary of the criteria coders use to distinguish when a service is critical (99291) versus complex and life threatening (99285):
Critical care is a time-based code and your documentation must include notation of a minimum of 30 minutes of critical care—exclusive of any separately billable procedures. The CPT critical care definition permits critical care to be provided in one or more separate periods and added together to determine the total time. The periods do not have to be continuous. In addition to documentation of at least 30 minutes of critical care, CPT requires documentation describing the following:
- Decision-making must be of high complexity to assess, manipulate and support vital organ systems to treat vital organ failure and/or prevent further deterioration.
- Both the illness/injury and treatment have to meet critical care requirements.
- The physician must devote his or her full attention to the critically ill or injured patient and can not provide services to any other patient during the same period of time. This time does not have to be spent at the bedside but could be spent elsewhere in the ED performing tasks such as reviewing lab results, consulting with another MD, documenting, etc.
CPT provides several examples of patients meeting the requirements for the critical care level of service including a 15 year old with acute respiratory failure from asthma, a 6 month old with hypovolemic shock secondary to diarrhea and dehydration, and a 3 year old with respiratory failure secondary to pneumocystis pneumonia.
CPT defines a level 5 service as one that requires a comprehensive history and exam and medical decision making of high complexity. In addition, the presenting problems are usually of high severity and pose an immediate significant threat to life or physiologic function. CPT provides examples of patients that meet requirements for level 5 services including a patient with a complicated overdose requiring aggressive management, a patient with a new onset of rapid heart rate requiring IV drugs, a patient with chest pain compatible with cardiac ischemia or pulmonary embolus, and a patient with a new onset of a CVA.
A critical care service might be required and performed for patients presenting with any of the level 5 problems listed above. Critical care applies when the illness/injury severity, management intensity, and interventions are unusually high. To support a critical care service, the physician’s documentation should explain the critical nature of the patient’s condition. It is helpful to document why a particular system was in danger of “failing.”
Before assigning critical care, coders assess each record’s documentation for evidence that the patient’s severity of illness and intensity of service are consistent with the CPT definition of critical care services. Common indicators of severity are documentation of unstable vital signs, altered mental status, serious cardiac arrhythmias or multiple injuries. These are the type of “flags” that auditors ask us to show them so that they can accept our designation of the service as requiring critical care. Patients described as “alert and in no acute distress” will rarely meet documentation criteria for critical care. For those patients where the necessity to provide critical care service may not be obvious, a narrative discussion that defines the critical nature of the care is essential.
Help Minimize Medical Necessity Denials in Your ED…
Enforcing a new requirement in the Medicare Modernization Act (MMA), the Centers for Medicare and Medicaid Services (CMS) required Fiscal Intermediaries (FIs) to revise their processing of ED claims for dates of service on or after November 22, 2004. The new rule requires FIs to pay for the EMTALA mandated screening and stabilization services provided in the ED.
Historically, FIs have edited claims or line items on claims based on diagnosis (medical necessity) or frequency of service provided (multiple lab tests, etc) which sometimes resulted in denials of billed ancillary service charges. Hospitals have turned to physicians to improve documentation of the diagnoses or symptoms that drove the decision to order a particular test. In effort to stem the revenue loss LYNX coders have used Medicare’s Local Medical Review Policies (LMRPS) and Local Coverage Decisions (LCDs) information to make sure they coded the correct ICD-9 codes.
Under the new MMA requirements Medicare is now stressing to providers the importance of documenting and coding presenting symptoms in addition to diagnoses for ED encounters. LYNX coders identify and code these symptom ICD-9 codes and they are then reported on the UB 92 claim form as either the ED “Reason for Visit” or as additional ICD-9 diagnosis codes. Of benefit to providers, CMS rules now require that Medicare systems scan all diagnosis fields on the claim for payable codes.
The MMA further requires that decisions about an ED service being “reasonable and necessary” be based on:
- The information available to the ED Clinician at the time of the visit
- The patient’s presenting problem or symptoms, and not only on the principal diagnosis.
The MMA specifically requires that denial for tests not be based on the number of tests performed and FIs have been instructed to turn off the LMRP/LCD frequency edits in their claims processing software for revenue code 45X (ED), among others. The law further states that “contractors may continue to target their data analysis on EDs to ensure that there are not aberrant patterns or outliers.” The FIs have been instructed to reopen any ED claim denied on or after January 1, 2004, if requested by a provider. ED physicians or mid-level providers can assist in minimizing denials for diagnostic tests by documenting why a particular test or study was ordered. If the ED Clinician documents an “indication” for each test—a symptom or diagnosis—coders can then code these to provide the medical necessity information payers are looking for.
Smooth Operations
Yearly Chargemaster Update Reminder
By Shannon Weintraub, MBA
Director of Coding Operations/QM
It is that time of year again and many professional groups choose this time of year to implement fee schedule updates or other changes to their CDM. If your group has made a recent change to your Chargemaster, either by adding/deleting CPT’s or changing/updating fees please remember to contact LYNX and provide a copy of the updated charge master.
It is important that our CDM reflect any changes made by the group in order for us to provide the best possible service as well as accurate reporting. If your group has not yet made a change, and you would like assistance in your Chargemaster review please let your LYNX coding operations manager know and they can assist you with that process.
If you have questions or would like to discuss recent changes to your Chargemaster, please feel free to contact your LYNX coding operations manager or myself by email or telephone 800.767.5969.
Compliance Corner
New 2005 CPT Reporting Language for Coding Ultrasounds
By Ann Florer, RN, CCS-P
Coding Compliance Manager
Ultrasound technology is rapidly being incorporated into the practice of emergency medicine, with emergency physicians becoming credentialed to perform ultrasound examinations as well as resultant interpretation and report.
When selecting the appropriate CPT code for ultrasound, the area and detail of the anatomy studied and not the type of equipment or size of the unit used (stationary vs. hand held) determines code selection.
New guidelines in 2005 CPT provide specific instructions for specific anatomical regions that have both “complete” and “limited” codes. In addition, CPT provides requirement as to permanent image storage.
Use of ultrasound without thorough evaluation of organ(s) or anatomical regions, image documentation and final written report is not separately reportable.
Codes for diagnostic ultrasound examinations are considered to be “complete” studies unless specified as “limited” studies in their CPT code definitions.
A complete abdominal ultrasound exam, 76700 consists of B mode scans of liver, gallbladder, common bile duct, pancreas, spleen kidneys and the upper abdominal aorta and inferior vena cava, including any demonstrated abdominal abnormality.
If less than the required elements for a “complete” exam are reported (limited number of organs or limited portion of region evaluated, a “limited” code can be reported if one exists in CPT. For example CPT code 76705-Ultrasound, abdominal, B-scan limited (eg. single organ, quadrant, follow-up).
When a limited exam is performed and a separate CPT “limited” code does not exist, no procedure can be assigned.
Diagnostic ultrasounds as well as ultrasound-guided procedures require permanently recorded images with measurements, when clinically indicated. A final written report should be issued for inclusion in the patient’s medical record. The report should contain a description of designated elements for inclusion for “complete” and “limited” ultrasound, or the reason that an element could not be visualized (e.g., obscured by bowel gas, surgically absent, etc.).
References
- AMA, CPT 2005-Diagnostic Ultrasound
- AMA, ACR, Clinical Examples in Radiology, Inaugural Issue 2004
- ACEP Emergency Ultrasound Guidelines—2001 (www.acep.org)
- ACEP Emergency Ultrasound Coding and Reimbursement (www.acep.org)
- Use of Ultrasound Imaging by Emergency Physicians (Policy number 400121) www.acep.org
If you have questions or would like to discuss the policy/documentation standards, please contact your coding manager.
The information contained herein is provided for informational and educational purposes only, and nothing contained herein should be construed as advice. All information contained herein is obtained by LYNX Medical Systems (LYNX) from sources believed by LYNX to be accurate and reliable. Because of the possibility of human and mechanical error as well as other factors, LYNX is not responsible for any errors or omissions. LYNX makes no representations and disclaims all expressed, implied, and statutory warranties of any kind to user and/or any third party including warranties as to accuracy, timeliness, completeness, merchantability or fitness for any particular purpose.