Critical Care Coding in the ER

Critical care coding in the ER is a specific section of evaluation and management coding.

It involves only two codes which are 99291 and the add on code 99292 which can not be used alone. As far as E/M coding goes this is relative easy to do as it is time based. The key for the coder is to know what can and can not be used in the time management of a critical care patient. This is what will trip up most coders.
Documentation by the physician is extremely important for critical care coding. If you look at your CPT® manual guidelines you will see that there is a lot going on for these two critical care coding E/M codes.

Critical Care Coding
If we break down what is required to use these codes it will fall into place. The physician must consider if the patients condition is going to deteriorate if he or she does nothing. Do not mistake how sick the person is but rather if life threatening deterioration is a high probability. The patient does not have to be unstable to qualify for critical care.
For example if a patient is bitten by a venomous snake and is brought into the ER quickly his condition may be stable at the time he is brought in. The patient can verbalize that he 
was bitten by a rattle snake thirty minutes prior on the left hand and a bite is visible with
swelling and discoloration. The patients vitals signs may even be within normal ranges.
What the physician knows is that his condition is going to deteriorate quickly as the
venom starts working.

Since critical care coding guidelines tell us it is time based the clock for 
this case starts right away. Included in this time would be the physicians full attention to 
the patient. This means not only time spent at the patients bedside but also in looking at 
the lab work, location of proper anti-venom, consultation with a specialist regarding care, 
talking with the patients family if the patient is no longer able to correspond and
documentation of the service. If the patient becomes stable and the physician takes care
of other patients then the clock stops.

The time does not have to be consecutive. When
the patient take a turn for the worse then the clock picks up where it left off.
Let us see how this plays out. Patient is brought into the ER by friends 30 minutes
after he is bitten by a rattle snake on the left hand. The snake was killed and brought in
 with the victim so the species is confirmed. The time is 1:00 p.m.. Dr Good sees the 
patient and orders tests and starts an IV which takes 20 minutes. He spends 15 minutes
with Dr. Nice who treated a similar case the previous week. A phone conversation lasting
10 minutes to the pharmacy for an anti-venom order. Patient is stable but Dr. Good
discusses patients condition with wife getting additional history for 20 minutes while the
patient doses with pain medication on board. Patient is still stable so he decides to leave
for a quick lunch in the cafeteria. He is gone a total of 15 minutes.

While gone the patient
slips into V-Tac and exhibits respiratory distress. Dr. Good rushes back to the patients
side. The anti-venom arrives via transport and Dr. Good does not leave the patients side
for 60 minutes. The time is now 4:00. If the critical care clock stopped at this point it
would be as follows 99291×1, 99292×2 for 105 minutes of critical care. Time is based
on documentation: 20+15+10+20+60=125 minutes total was documented care.
Critical care is reimbursed at a higher level and is a prime target for auditors
therefore it is essential to follow the CPT® coding guidelines carefully. This takes 
teamwork between the physician and the coder to make sure quality documentation is 

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