Prolonged and Critical Care CodesWhen to bill and what needs to be documented…..

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.

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”

What Codes to Use and Documentation

• Can be used with Inpatient/Outpatient, initial/established patients, consults/follow ups.

Minutes of Service Code

Under 30 Not reported separately

30 – 74 99354 (OP) or 99356 (IP)

75 - 104 99354 + 99395(OP) or 99356 + 99357 (IP)

105 - 134 99354 + 99395 X 2 (OP) or99356 + 99357 X 3 (IP)

Standard Times for Outpatient Visits:

Time: New Patients: Est. Patients: Consults:

5 min 99211

10 min 99201 99212

15 min 99213 99241

20 min 99202

25 min 99214

30 min 99203 99242

40 min 99215 99243

45 min 99204

60 min 99205 99244

80 min 99245

Standard Times for IP Visits:

Time: Admits: Follow Ups: Consults:

15 minutes 99231

20 minutes 99251

25 minutes 99232

30 minutes 99221

35 minutes 99233

40 minutes 99252

50 minutes 99222

55 minutes 99253

70 minutes 99223

80 minutes 99254

110 minutes 99255

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.

Correctly Using Critical Care Codes

• Can include all time spent evaluating, providing and managing patient’s care, as long as physician is immediately available 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!!!!

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)

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.

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

Time: Codes:

Less than 30 minutes E/M code, not critical care

30 – 74 minutes 99291

75 – 104 minutes 99291 + 99292

105 – 134 minutes 99291 + 99292 X 2

How to Use Critical Care Codes

Now let’s look at some examples!!!!

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

JENI SMITH, CPC(352) 733-0217J.SMITH@UFL.EDU

Questions?????