BILLING, CODING, AND DOCUMENTATION IN THE CRITICAL CARE ENVIRONMENT

CRITICAL CARE OF THE TRAUMA PATIENT

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BILLING, CODING, AND DOCUMENTATION IN THE CRITICAL CARE ENVIRONMENT Samir M. Fakhry, MD

The current health care environment has resulted in dramatic changes in the economic reality for practicing physicians. The traditional fee-for-service system allowed physicians to be reimbursed for their workload regardless of almost any other consideration. It was essentially a work-bill-collect arrangement that is used successfully by many professions. The current reimbursement system in US health care is substantially different because of the introduction of a set of different paradigms (including managed care). To many physicians, these models often involve reimbursement based on seemingly arbitrary standards unrelated to actual physician work. This professional reimbursement arrangement is uncommon among professions in the United States in which compensation typically is driven by market forces. The explanations for the predicament in health care reimbursement are complex, controversial, and beyond the scope of this article. The realities of the marketplace finally caught up with health care providers when the costs of health care became so high as to force large US employers to seek alternatives. In addition, the perceived excess percentage of gross national product devoted to health care costs prompted government, large insurers, and payers (mostly business concerns) to demand lower costs for health care delivery. Interestingly, there has been relatively little interest in assessing the value rendered by the health care system in the United States for the expenditures of health care dollars. As things stand now, most physicians earn smaller salaries (on average, 3.4% less) this year while providing equal or greater volumes of service.' Current standards for billing, coding, and documentation are more stringent and complex than ever before. Mistakes in coding and billing are rarely tolerated, and delays are costly. In a series of recent federal laws and regulations, Congress and the federal government have stated clearly that inaccurate coding, billing,

From Trauma Services, Inova Fairfax Hospital, Falls Church, Virginia; and the Department of Surgery, Georgetown University School of Medicine, Washington, DC

SURGICAL CLINICS OF NORTH AMERICA VOLUME 80 * NUMBER 3 *JUNE 2000

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and documentation for Medicare patients constitutes fraud and abuse. An updated version (1986) of a Civil War era antifraud law, the False Claims Act, allows ordinary citizens to file suit against providers defrauding the government and keep part of recovered monies. Stark I (1989) and Stark I1 (1995) address referral arrangements, such as physician ownership of laboratories to which they refer their patients. A reinterpretation of Intermediary Letter 372 (IL 372, effective 7/ 1/96) has drastically reset the requirements for billing Medicare by ”teaching” physicians supervising residents. An upgraded Fraud and Abuse section was created in the Medicare Carrier’s Manual. The Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), also known as the Kassebaum-Kennedy Bill, was primarily designed to ensure that individuals could retain their health insurance as they change jobs. The act also contains several provisions intended to combat fraud and abuse in health care. The bill extends Medicare antifraud and abuse regulations to other health care programs that receive government funding and increases applicable penalties in cases of fraud and abuse. Importantly for practicing physicians, the act defines criminal penalties for health care fraud and abuse and creates a federal program to combat such activity. The Attorney General, the Office of the Inspector General, the Federal Bureau of Investigation, and Medicare contract carriers received more than $600 million in 1997 and are scheduled to receive more than $1 billion by 2002 for antifraud and abuse activities4 Several hospitals and physicians have been severely penalized by the federal government for alleged fraudulent billing practices and poor documentation. Federal legislation has extended the fraud and abuse provisions to include the private sector also. Federal law also allows the government to repossess personal property derived from health care fraud. Whereas in the past it may have been possible to be relatively cavalier about coding, billing, and documentation, today’s surgeons cannot afford to be anything but knowledgeable, accurate, and complete if they expect to maintain a fair and appropriate stream of income and to avoid potential criminal prosecution. Most practicing physicians received little formal training in medical school, residency, or practice regarding the “business” side of medicine, let alone the specific requirements for proper coding, billing, and documentation. As changes in the health care reimbursement system continue, it becomes increasingly costly for individual surgeons and their professional organizations to ignore the need for a better understanding of the current system. It quickly becomes obvious to the initiate in this field that the manner in which physician work is supposed to be documented and the systems for coding and billing are less than p e r f e ~ t . ~ This was exacerbated when new Documentation Guidelines for E & M services (so-called “cognitive services”) were released in May 1997 by the American Medical Association (AMA) and the Health Care Financing Administration (HCFA).These guidelines were extremely complex, requiring detailed recording of the history; review of systems; past, family, and social history; and physical examination. A system of ”bullet points” and checklists was involved that would have transformed most physician-patient encounters into painstakingly laborious and time-consuming essay-writing sessions. The implications for patient care are o b v i o ~ s , ~as , is the implicit assumption that most physicians are trying to defraud third-party payers. The new guidelines were meant to go into effect in July 1998 with the stated intent of quantitating E & M services and combating fraud. The medical community (including the AMA’s own House of Delegates) reacted with outrage, and the implementation of the guidelines was delayed indefinitely. The emphasis on combating perceived fraud and abuse, however, continues at the federal level, and physicians should clearly take

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notice. This has had the predictable effect of increasing demand for consultative and educational services to improve physician documentation, coding, and billing (at significant cost) and has provided the impetus for articles such as the one you are reading. For physicians at teaching hospitals, this heightened emphasis comes on the heels of the upgraded requirements for physician documentation involving residents. The pressure for attending surgeons to write or dictate their own admitting and progress notes, operative notes, and bedside-procedure notes continues to increase. The implications for resident education are potentially significant. This article reviews documentation guidelines for critical care and discusses appropriate coding and billing strategies. No matter what the practice setting or the experience of the surgeon, working collaboratively with an individual knowledgeable and experienced in documentation, coding, and billing is invaluable. Given the frequent changes in regulations and reimbursement and the threats of audit, such individuals are well worth their salaries. In addition, each surgeon should personally review and become comfortable working with the following publications: the CPT handbook, the ICD-9 CM handbook, and HCFA / AMA Documentation Guidelines for Evaluation and Management Services.6 The 1995 (currently in place) and the 1997 (proposed but not implemented) guidelines are of interest. To ensure that they are fairly and promptly reimbursed for the professional services that they provide, physicians must have, at minimum, a basic understanding of the various components of the processes of documentation, coding, and billing. In addition, a working knowledge of the relevant agencies and organizations collectively referred to as thirdparty "payers," or insurers, is of importance. This article is not a substitute for a comprehensive educational program in documentation, coding, and billing. GOVERNMENTAL AGENCIES, THIRD-PARTY PAYERS, AND INSURERS Health Care Financing Administration HCFA, of the Department of Health and Human Services, was established in 1977 as the federal agency that administers the Medicare, Medicaid, and Child Health programs. HCFA oversees the reimbursement of physicians and hospitals under Medicare and Medicaid, including promulgating the regulations for physician documentation, and charge submission and payment. Most insurers adopt HCFA's standards and regulations for physician reimbursement. A thorough knowledge of these standards and regulations is therefore mandatory for successfully billing not only Medicare but also most insurers. Medicare In 1965, Title XVIII of the Social Security Act, entitled Health Insurance for the Aged and Disabled, was established to complement existing provisions of the Social Security Title XVIII is commonly known as "Medicare" and is the nation's largest health insurance program. It provides coverage to 38.1 million Americans. Medicare provides health insurance to people aged 65 or over, those who have permanent kidney failure, and certain people with disabilities. Medicare costs as a percentage of federal budget outlays grew from 3.2% ($6.2 billion) in 1970 to 11.2% ($174.2 billion) in 1996. During that same period, the number of enrollees increased from 20.5 million to 38.1 million individual^.^

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To bill Medicare, physicians (“providers”) must submit an application to Medicare and be approved. Once physicians are approved as providers, they are assigned a provider number and unique physician identification number (UPIN). HCFA is developing a new physician number, the national provider identifier (NPI), as a unique identification number for health care providers that will be used by all insurance providers. The NPI will ultimately replace the UPIN. Groups working together are assigned a group number, and the individual provider number must be provided together with the group number for documentation. All of these identifiers must appear on claims submitted to Medicare. Before 1992, physicians were paid on the basis of reasonable charge. This was initially defined as the lowest of (1) the physician’s actual charge, (2) the physician’s customary charge, or (3) the prevailing charge for similar services in that locality. Starting in January 1992, allowed charges were defined as the lesser of the submitted charges or a fee schedule based on a relative value scale. Payments for durable medical equipment and clinical laboratory services are also based on a fee schedule. Hospital outpatient services and home health agencies are currently reimbursed on a reasonable cost basis. The Balanced Budget Act of 1997 provided for implementation of a Prospective Payment System for these services in the future. If a doctor or supplier agrees to accept the approved rate as payment in full (takes assignment), then payments provided must be considered as payment in full for that service. No added payments (beyond the initial annual deductible and co-insurance) may be sought from the beneficiary or insurer. Thus, if a physician signs the standard agreement to accept Medicare’s allowances (i.e., the amount Medicare allows physicians to charge for each procedure or service) and thereby reduce his or her professional fees accordingly, that physician is considered a participating provider. Physicians are ”participating” physicians if they agree before the beginning of the year to accept assignment for all Medicare services that they furnish during the year. Physicians are required to bill patients for copayments and deductibles. If the provider does not take assignment, the beneficiary is charged for the excess (which may be paid by medigap insurance). Limits on the excess that doctors or suppliers can charge now exist. Medicare claims are processed by nongovernment organizations or agencies that contract to serve as the fiscal agent between providers and the federal government to locally process Medicare claims. These claims processors are known as internzediaries and carriers. Intermediaries’ responsibilities include: Determining costs and reimbursement amounts Maintaining records Establishing controls Safeguarding against fraud and abuse or excess use Conducting reviews and audits Making the payments to providers for services Assisting both providers and beneficiaries as needed Carriers’ responsibilities include: Determining charges allowed by Medicare Maintaining quality of performance records Assisting in fraud and abuse investigations Assisting suppliers and beneficiaries as needed Making payments to physicians and suppliers for services that are covered

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They apply the Medicare coverage rules to determine the appropriateness of claims. Medicare intermediaries process claims for institutional services, including inpatient hospital claims, skilled nursing facilities, home health agencies, and hospice services. They also process hospital outpatient claims. Examples of intermediaries are the Blue Cross and Blue Shield Association (through their plans in various states) and other commercial insurance companies. Medicare carriers handle claims for services by physicians and medical suppliers. Examples of carriers are the Blue Shield plans and various commercial insurance companies. Peer review organizations are groups of practicing health care professionals paid by the federal government to do general overview of care provided to Medicare beneficiaries in each state and to improve quality of services. Peer review organizations educate and assist in the promotion of effective, efficient, and economical delivery of health care services to their Medicare population. The filing deadline for submitting Medicare charges is December 1 of the year following that in which the service is provided. Only participating providers can appeal denied payments to Medicare. These appeals must be filed withn 1 year of the denial. Medicaid

HCFA describes Medicaid as a ”jointly funded Federal-State health insurance program for certain low-income and needy people.”8 It covers approximately 36 million individuals, including children; the aged, blind, or disabled; and people who are eligible to receive federally assisted income maintenance payments.8Broad national guidelines have been established by federal statutes for Medicaid. Each state independently establishes eligibility standards; sets the type, amount, and duration of services; sets the rate of payment for services; and administers its program. Medicaid policies for eligibility, services, and payment are complex and vary considerably among states. The billing requirements for Medicaid are similar to those for Medicare. Physicians must submit an application and be approved. Once physicians are approved as providers, they are assigned provider numbers. Groups are assigned group numbers, and the individual provider number must be provided together with the group number for documentation. All of these identifiers must appear on claims submitted to Medicaid. Medicaid pays only participating providers. As a Medicaid provider, a physician must accept Medicaid allowances as payment in full and may not bill patients for the balance. Nonparticipating physicians may bill neither Medicaid nor the patient. The filing deadline for submitting Medicaid charges varies among states because Medicaid programs are administered at the state level. Only participating providers can appeal denied payments to Medicaid. These appeals must be filed within 12 months of the denial. Blue CrosdBlue Shield

The Blue Shield companies are a diverse group of insurers under license from the national organization to use the trademark name. When physicians contract with a regional Blue Shield plan, they accept the set fees (“allowances”) offered. Patients are billed a copay and any deductibles. In general, providers agree to write off any charges denied by Blue Shield unless they are successfully

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appealed. Filing limits vary by location, as do the deadlines for appeals. Only participating providers may appeal a Blue Shield denial. Of relevance to critical care, some Blue Shield plans continue to bundle bedside procedures ( e g , central venous catheter or pulmonary artery line placement) into the critical care billing codes, thereby denying payment for such procedures when critical care codes are used. Commercial Insurance

Commercial insurance carriers interact with physician-providers in a more traditional (or capitalistic) manner. Much like businesses in general, physicians submit charges for care provided, with the expectation of being paid. Physicians do not sign provider agreements and professional fees are not reduced or set by prior agreement or contract. A valid tax identification number or social security number is required for payment for tax purposes. After physicians submit professional charges, insurers may not pay the full fee but instead pay the ”usual and customary” amount. The timely filing limit is usually 1 or 2 years. All physicians may appeal a payment denial by the company. Worker’s Compensation and Liability

The billing requirements for worker’s compensation are similar to those of commercial insurers. Physicians must accept the payment provided and may not appeal. If a claim was not properly processed, an appeal may be filed. Filing limits vary depending on the carrier and type of injury. In liability cases, physicians bill in similar fashion to commercial insurance companies. Payment may be at full value or subject to the terms of the settlement or court decision. Physicians may not receive payment if the case is not resolved. Appeals are not allowed in such cases. Each state has it own rules governing the process, and these may vary substantially. DOCUMENTATION, CODING, AND BILLING

The conversion of physicians’ professional work into remuneration should, ideally, be seamless, straightforward, and fair. Under the current reimbursement system, the process begins with documentation, followed by coding and then billing. Each step is closely linked to the one that follows and provides justification and ”evidence” for the reimbursement requested. The more completely and accurately each portion of the process is completed, the greater the likelihood of payment in a timely and complete manner and the lower the risk for allegations of fraud or abuse in an audit. Documentation refers to the notations that physicians make in patients‘ medical records of professional services rendered. This process has become increasingly complex and burdensome to physicians because additional requirements continue to be introduced by payers, predominantly governmental agencies. The nongovernmental payers routinely follow suit, however, making the adoption of governmental standards for all patients simpler. Coding refers to the process of selecting (1) a numeric descriptor of the professional service provided and (2) the medical diagnosis prompting physicians to provide that service. The importance of providing medical diagnoses to

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support the service being coded (i.e., linking diagnosis codes to billing codes) cannot be overemphasized. Diagnoses are described using the International Classification of Disease system, currently version 9 (ICD-9 CM). Coding for procedures (e.g., surgery, central line placement, or lumbar puncture) and nonprocedural or ”cognitive” services (referred to as evaluation and management, or E b M codes) requires the use of the Current Procedural Terminology (CPT) system. The CPT codes were developed by the AMA in collaboration with HCFA and are updated periodically. Procedure codes are provided for most operations and generally allow physicians to describe the procedure performed by using a standardized listing by body area (e.g., intestinal surgery) or type of service (e.g., central venous catheter placement). Codes for E & M services are the area of greatest difficulty and contention for physicians when translating work into numeric descriptors. Billing is the recording of charges for services rendered, together with the appropriate descriptive CPT codes and supporting diagnoses in the format required by third-party payers. The billing document is then submitted to the payer. Charges submitted to Medicare or Medicaid are recorded on HCFA form 1500. In addition to patient demographic information, key entries include the CPT billing code(s), modifiers as needed, the requested dollar amount, four supporting diagnoses, and physicians‘ identification numbers. Other payers have similar (but separate) charge submission forms. The process of submitting bills is best left to an individual or group with the experience and time to properly complete the needed paperwork. Physicians rarely have the time or experience to optimally fill out billing forms, respond to denials, and pursue collections. The author strongly recommends a basic knowledge of physicians’ own practice’s billing routines and frequent scheduled meetings to review overall charge activity, accounts receivable, denials, explanation of benefits (EOB), and fee schedules. The EOB is the payer’s comment or clarification of an action (e.g., a reduced payment or denial) taken or recommended with regard to a bill that a physician has submitted. Physicians may choose not to review all EOBs and denials because many are routine or expected. Unexpected or unusual EOBs always should come to physicians’ attention because important information may be included within these forms, such as warnings about improper use of codes or charges that, if ignored, may prompt an audit. PRACTICAL CONSIDERATIONS Writing (or Dictating) Notes

Physicians always have provided high-quality documentation in medical records as part of optimal patient care. Now, physicians must provide adequate documentation in view of the serious penalties they may incur otherwise. The adage ”If it is not documented it did not happen” often has been used in the context of protecting physicians from litigation. It could just as easily apply to documentation as far as reimbursement and insurers are concerned. It is physicians’ responsibility to provide legible documentation in medical records that accurately reflects care delivered and procedures performed. The entry must be signed and the provider’s name must be legible. Important changes recently have occurred in guidelines for documentation. As a minimum preliminary step, physicians should read the entire section on E & M coding in the current edition of the CPT manual. The requirements for documentation in the medical record were relatively straightforward and simple before 1992. There were several levels

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of clinical service (i.e., brief, limited, and intermediate), and the directions took up seven pages in the CPT manual? In January of 1992, HCFA introduced new E & M guidelines that took up 44 pages in the CPT manual. Four categories of history, four of physical examination, and multiple levels of medical complexity in decision making were used to determine the level of service provided and the documentation required. An additional modification occurred in 1995 that categorized portions of physicians’ notes by body areas and organ systems. The proposed guidelines introduced in 1997 included substantially more complex documentation requirements but caused such an uproar that they continue to be deferred. Although computerized forms with preformatted or standardized text are considerably appealing, such documentation methods are more likely to be negatively viewed at audits. Similarly, forms with extensive use of check-off boxes or fill-in-the-blanksand notes that appear similar among differing patients may be “red flags“ for audits. Many such practical issues can be readily identified during an internal audit. Implementing internal self-audits, external reviews by consultants, and effective compliance programs not only decreases the risk for audit exposure but also enhance the efficiency of a practice and its revenue stream. Selecting the Appropriate Code

In the critical care environment, a few options exist for coding professional services. The most commonly used codes in the critical care setting are listed in Table 1. Unique CPT codes (99291 and 99292) exist for billing critical care services in a critical care setting (Table 1).The critical cure setting is defined as any area where critical care services are provided and is not limited to the ICU. No training or specialty requirement exists for physicians to bill critical care codes. The medical specialty that bills the highest number of critical care codes is family medicine. The 99291 code and the related 99292 code are distinguished by being time based. This makes it important to document the time spent in attendance as part of physicians’ notes in medical records. Physicians must spend at least 30 minutes in attendance before the 99291 code can be used. If physicians spend more than 60 minutes in attendance, they may use the 99292 code in addition to 99291. When using the 99292 code, the time spent in excess of 1 hour must be at least 15 minutes (i.e., total time must be at least 75 minutes to warrant using 99292 with 99291). Additional time is coded and billed similarly by adding as many 99292 codes as necessary. All providers in the same group billing under the same ID number are considered interchangeable when calculating time for critical care codes. Thus, if one partner bills for the first hour of critical care (99291) and then turns the patient’s care over to the other partner, the second partner cannot bill 99291 again on the same date; rather, the ”clock keeps running,” and the second partner bills additional time as 99292 as if the same doctor were caring for the patient. If different physicians from separate practices are providing critical care, each may use 99291 once daily. Although the definitions of several terms within the CPT guidelines prior to 2000 for the critical care codes are controversial, a 1995 memorandum from Elizabeth Cusick, Director, Office of Physician and Ambulatory Care Policy at HCFA, provides important clarification (unpublished, 1995). The memorandum considered that the literal translation of a ”medical emergency” was ”too narrow and restricts the use of the critical care codes inappropriately.” Instead, critical

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Description

Each additional 30 min

Ventilator management 94656 Initial ventilator management 94657 Subsequent ventilator management

Follow-up consultation 99261 Follow-up inpatient consultation, Level 1 99262 Follow-up inpatient consultation, Level 2 99263 Follow-up inpatient consultation, Level 3

Subsequent hospital care 99231 Subsequent hospital care, brief 99232 Subsequent hospital care, intermediate 99233 Subsequent hospital care, comprehensive Initial consultation 99251 Initial inpatient consultation, Level 1 99252 Initial inpatient consultation, Level 2 99253 Initial inpatient consultation, Level 3 99254 Initial inpatient consultation, Level 4 99255 Initial inpatient consultation, Level 5

99292

Critical care codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient requiring the constant attendance of the physician; first hour

CPT Code

First day of establishing ventilator management, cannot be used with 99291/99292. Subsequent days ventilator management, cannot be used with 99291/99292.

These visits are consultations to complete the initial visit or subsequent consultation requested by the attending physician. If the consultant initiated therapy at the initial visit and is participating in the patient's management, use 99231-33.

The surgeon is acting in a consulting role managing another physician's patient. The full name of the physician requesting the consult must be documented legibly. The consultant's recommendations should be clearly noted, communicated to the consulting physician, and so noted in the record. The consultant cannot assume total care of the patient. If the consultant continues to see the patient on subsequent days, either a critical care code or a continuing care code is used.

For established patients who do not clearly qualify for a critical care code. The level chosen must be consistent with the care delivered and the documentation in the record (see text). Used for patients receiving less than 30 min of critical care.

30-74 min of constant attendance (need not be consecutive) for a patient who is critically ill or injured to assess, manipulate, and support circulatory, respiratory, central nervous, or other vital system functions to prevent or treat single or multiple organ system failure. This often requires extensive interpretation of multiple databases and the application of advanced technology to treat the patients. Do not bill bundled services such as ventilator management with a critical care code. Do not count the time spent performing unbundled procedures towards the critical care code. 75-104 min total constant attendance (need not be consecutive); use in addition to 99291 and add as many instances of 99292 as warranted based on total time in attendance. Total time billed cannot exceed 24 h for all patients combined.

GuidelinedSuggestedClinical Situation

Table 1. SELECTED EVALUATION AND MANAGEMENT CODES USED IN THE CRITICAL CARE SETTING

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Table 2. SERVICES BUNDLED WITH CRITICAL CARE CODES 99291/99292 CPT Code

Description

94656, 94657, 94660, 94662 93561, 92562 71010, 71020 99090

Ventilation management Interpretation of cardiac output measurements Interpretation of chest radiographs Interpretation of blood gases and information stored in computers Gastric intubation Temporary transcutaneous pacing Vascular access procedures*

91105 92953 36000, 36410, 36415, 36600

*Only the codes listed are included: venipuncture and arterial puncture. This billing code does not include central venous access, arterial line placement, or pulmonary artery catheter. CPT = current procedural terminology.

care "also includes the care of patients who might not be in a medical emergency but who nonetheless require constant physician attention because they are unstable and critically ill or unstable and critically injured." A caution that not all patients in an ICU qualified for a critical care code was included. The memorandum also clarified that "constant attendance" and "constant attention" did not imply that physicians must be at the immediate bedside constantly. Physicians were permitted to include "time spent engaged in work directly related to the individual patient's care whether the time was spent at the immediate bedside or elsewhere on the floor or unit. For example, time spent reviewing laboratory test results or discussing the critically ill patient's care with other medical staff on the unit or at the nursing station on the floor would be reported as critical care even if it did not occur at the bedside." Needless to say, if a physician's progress note begins with the ubiquitous "stable and afebrile," the patient is unlikely to qualify for a critical care code. Several services may be provided to critically ill patients that are included in the 99291/ 99292 codes (Table 2). The most important of these bundled services is management of the mechanical ventilator. Under other circumstances, physicians could bill separately for such services. When using the critical care codes, however, billing for such bundled services together with 99291/ 99292 results in a denial of all charges or payment of the least remunerative. Many services, such as endotracheal intubation (CPT code 31500) and placement of a pulmonary artery catheter (CPT code 93503) were originally bundled with 99291/ 99292. In 1993, these and several other services and procedures were "unbundled" from 99291/ 99292. The unbundled services should be billed in addition to the critical care code. The time spent performing such unbundled services is not included in the determination of the total time for 99291/ 99292. The new CPT 2000 guidelines have helped clarify the confusion regarding critical care codes. A memorandum recently distributed by HCFA to its Program Carriers Iwww.hcfa.gov/ pubforms/ transmit /b994360.htm) has resulted in a much clearer set of guidelines for the carriers to use in evaluating charges submitted using the 99291 critical care code. The memorandum delineates three important criteria for the carriers to use in determining if a billable activity qualifies for a critical care code:

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Clinical condition criterion: “There is a high probability of sudden, clinically significant, or life threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently” Treatment criterion: “Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition” Documentation of time: For example, “Critical care time: 45 minutes excluding procedures” written legibly at the end of the physican’s note.

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Under the previous guidelines, many critically ill or injured patients would not have qualified for critical care codes because they were not clearly ”unstable”. As a result, many physicians were understandably reluctant to use the 99291 code despite the fact that they were providing a very complex level of care involving significant time at the bedside. With these clarifications in place, patients who have potentially serious or life-threatening conditions requiring direct personal management by the physician for 30 or more minutes will now qualify for the critical care codes. It is crucial that a clear reference to the time spent delivering critical care be included in the physician’s note. Time spent on procedures that are unbundled (and therefore should be billed separately from the critical care codes) cannot be counted as critical care time. Teaching time cannot be counted as critical care time. Time speaking with consultants or the family under the circumstances specified in the memorandum can be counted as long as it occurs in the ICU (even if it is by phone in the ICU). Phone calls from the physician’s office do not count, however. Time spent reviewing data, x-rays or other relevant information also counts as long as it occurs in the immediate vicinity of the patient. It should be noted that HCFA reduced the R W for the 99291 code by 10% (from 4 to 3.6). Other Codes for Patients in Critical Care Settings

The codes available for use in patients who are in a critical care setting but who do not qualify for the 99291/99292 codes include (see Table 1):Subsequent Hospital Care codes (99231, 99232, and 99233), Initial Inpatient Consultation codes (99251-99255) and the Follow-up Inpatient Consultation codes (99261, 99262, and 99263). In the 1995 AMA/HCFA guidelines, each type of E & M service includes multiple levels. The levels are determined based on seven components: (1)history, (2) physical examination, (3) medical decision making, (4) counseling, (5) coordination of care, (6) nature of presenting problem, and (7) time. The first three of these components (i.e., history, physical examination, and medical decision making) are considered the key components in selecting the level of E & M services. Four types of history are described in the AMA/HCFA guidelines: (1) Problem-focused, (2) Expanded problem-focused, (3) Detailed, and (4)Comprehensive. These are reviewed briefly here, but a thorough review of the original

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Table 3. DETERMININGTHE TYPE OF HISTORY FOR EVALUATION AND MANAGEMENT SERVICES History of Present Past, Family, or Illness Review of Systems Social History

Brief Brief Extended Extended

None required Problem pertinent Extended Complete

None required None required Pertinent Complete

Type of History

Problem-focused Expanded problem-focused Detailed Comprehensive

guidelines is highly recommended. Each type of history should include the chief complaint and some or all of the history of present illness; review of systems; and the past, family, and social history. The type of history is determined from the combination of these factors (Table 3). Four types of physical examination exist: (1) Problem-focused (i.e., a limited examination of the affected body area or organ system), (2) Expanded problem-focused (i.e., a limited examination of the affected body area or organ system and other symptomatic or related organ systems), (3) Detailed (i.e., an extended examination of the affected body area and other symptomatic or related organ systems), and (4) Comprehensive (i.e., a general multisystem examination or complete examination of a single organ system). Four types of medical decision making exist: (1) Straightforward, (2) Low Complexity, (3) Moderate Complexity, and (4) High Complexity. Medical decision making refers to the complexity of establishing a diagnosis and selecting a management option as measured by the number of possible diagnoses or management options available; the length and complexity of the medical record; diagnostic tests and other information evaluated; and the risk for significant complications, including comorbidities involved. Combining these allows physicians to determine the level of E & M service. An abbreviated schema for the Subsequent Hospital Care codes is presented in Table 4. Although such aids are useful, they are not a substitute for review of the full guidelines. Similar guidelines are available for the consultation codes. To be able to bill a consultation code, written documentation that a consultation was requested must exist. The surgeon providing the consultation should document the name of the consulting physician; the appropriate history, examination, and medical decision making (as required for the level submitted); and a notation that the assessment and recommendations were communicated to the consulting physician. If the consultant sees the patient again in a follow-up, a subsequent hospital code (992931992933) should be used. Only if the attending physician places a second request for consultation should the inpatient follow-up consultation codes (992961-

Table 4. ABBREVIATED SCHEMA FOR CODING SUBSEQUENT HOSPITAL CARE CPT Code

History

Examination

99231

Problem-focused

Problem focused

99232

Expanded problem-focused Detailed

Expanded problem-focused Detailed

99233 CPT

=

current procedural terminology.

Medical Decision Making

Approximate Time (min)

Straightforward / low Moderate

15 25

High

35

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992963) be used. The consultant should not assume the care of the patient. If the care of the patient is assumed, the consultation codes should not be used; instead, a critical care code or a hospital care code should be used. In many cases in the critical care setting, surgeons use the highest level code for subsequent hospital care (99233) for patients who are seriously ill but do not easily meet the requirements for a critical care code. This requires that two of the following three components be documented: 1. A detailed interval history, which in turn requires: a. An extended history of present illness b. An extended review of systems c. A pertinent past, family, and social history 2. A detailed examination, which must include at least six organ systems 3. Medical decision making that is of high complexity, consisting of at least two of the following three elements: a. Extensive number of diagnoses or management options b. Extensive amount or complexity of data reviewed c. High risk for complications or morbidity or mortality

Typically, these documentation requirements can be met in the interval physical examination and medical decision-making areas alone. Physicians should document at least six organ systems for physical examination, using caution to avoid counting those systems involved in adjunctive procedures (e.g., respiratory should be documented for code 94657 but should not add to the count of six organ systems for the examination). Also, physicians should document the laboratory data, radiographic data, consultant data reviewed, and pertinent abnormal values and negatives (to satisfy the requirement for amount and complexity of data). The therapeutic plan should be documented with a reference to the risk for morbidity. Although examination and medical decision making usually meet the requirements, the history can sometimes be one of the three elements by being a detailed interval history, which in turn requires: 1. An extended history of present illness 2. An extended review of systems 3. A pertinent past, family, and social history Using Modifiers

Modifiers are numeric codes added on to CPT codes to indicate a nonstandard circumstance requiring added consideration with regard to payment. Their primary utility for surgeons is to indicate to payers that a request for payment should not be denied without due consideration. A common circumstance is when a surgeon provides critical care services or procedures during the global period. Ordinarily, such a charge for E & M services would be denied. Using the appropriate modifier (-24 or -25 or -79; Table 5) more clearly describes the provider’s circumstances and should enhance the probability of timely and appropriate payment. In a physician group billing under the same identification number(s), the use of modifiers may be helpful because all of the physicians are considered as the same provider. In such instances, the modifiers can decrease the risk for denials or delays in payment while clarification is sought from the providers. Of utility in teaching hospitals is the GC modifier, indicating ”resident” involvement in a procedure. This is important for Medicare and Medicaid cases.

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Table 5. COMMONLY USED MODIFIERS FOR CRITICAL CARE Modifier

Description

- 24

Unrelated evaluation and management service by the same physician during a postoperative period: The physician may need to indicate that an E & M service was performed during a postoperative period for a reason unrelated to the original procedure. Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service: The physician may need to indicate that on the same day of a procedure or service identified by a CPT code, the patient’s condition required a significant, separately identifiable E & M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E & M service may be prompted by the symptom or condition for which the procedure or service was provided. As such, different diagnoses are not required for reporting of the E & M services on the same date (one of the few circumstances in which different diagnoses from the operative diagnosis are not required) Bilateral procedure: Bilateral procedures that are performed at the same operative session should be identified by adding the modifier ’ - 50’ to the appropriate five digit code Decision for surgery: An E & M service that resulted in the initial decision to perform the surgery may be identified by adding the modifier ’ - 57’ to the appropriate level of E & M service Repeat procedure by same physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. The circumstance may be reported by adding the modifier ’ - 76‘ to the repeated procedure or service Repeat procedure by another physician: The physician may need to indicate that a procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier ’ - 77’ to the repeated procedure or service Unrelated procedure or service by the same physician during the postoperative period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier ‘ - 79’

- 25

- 50

- 57

- 76

- 77

- 79

Adpated from American Medical Association, Current Procedural Terminology, 1999.

Other codes useful in describing procedures include -80 (surgical assistant) and -82 (surgical assistant, no qualified resident). Two other important modifiers applicable to procedures involve critically ill or critically injured patients. When a service provided is greater than that usually required for the listed procedure, it may be identified by adding modifier “-22” (Unusual Procedural Services) to the usual procedure code. Situations commonly quoted2 as justifying the use of this modifier include: Increased risk Difficult procedure Hemorrhage Severe respiratory distress Extended services Estimated blood loss of more than 600 mL Unusual findings

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Complications Prolonged operation Obesity Unusual contamination control From American Academy of Procedural Coders Independent Study Program, Module 2, 1996, pp 33 to 3-4; with permission.

Work and effort should have been increased 30% to 50% over the routine procedure. -22 Claims are usually kicked out of the automated process and sent to medical review. The operative report should describe in specific detail the entities justifying the -22 modifier, and the operative report should be included with the claim. Medicare payment increases are rarely more than 20%. Commercial payers typically allow an additional 20% to 30% reimbursement. The other modifier useful for critically ill or critically injured patients undergoing procedures is -59 (Distinct Procedural Service). This modifier is useful in circumstances in whch a physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day or at the same setting. When another, already established modifier is appropriate, it should be used rather than modifier -59. It may be applicable to situations such as exploratory laparotomy for hernoperitoneum in trauma in which a splenectomy is performed. Ordinarily, billing for splenectomy in the elective setting precludes billing for exploratory laparotomy; however, in trauma patients, exploratory laparotomy is not a part of splenectomy if it is being performed to fully evaluate the abdominal cavity for injury. The use of the -59 modifier in this situation should be reviewed with the billing manager or adviser and even with payers to ensure appropriate interpretation of the codes. Billing for Services in the Global Period Surgical patients in the critical care setting are often postoperative patients. The global fee concept prevents surgeons from submitting ordinary postoperative charges in the 90 days following surgery. Importantly, only the surgery and the operative diagnoses are affected. If the postoperative services are provided for diagnoses different from the operative diagnosis, billing is appropriate. For example, a surgeon provides critical care services (e.g., directing the bedside management, including fluid resuscitation, antibiotic administration, and mechanical ventilation) on the third day postoperatively for a patient in whom septic shock develops after a colon resection. These services justify a separate charge because the ordinary postoperative care provided in the global period to patients after colon resection does not involve such critical care services. The amount .of time spent in attendance should be recorded as part of the physicians’ note. The critical care service provided must be properly documented and coupled with the ICD-9 code for septic shock to differentiate it from the operative service and its diagnosis. Also, a modifier (in this case, -24 for Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period) is used to alert the payer to the special circumstance involved. Ordinarily, a separate charge for critical care services in the global period after colon resection would be automatically denied. The use of the modifier and the appropriate diagnostic code (99291-24) alerts the carrier and results in a much higher likelihood of payment. The key is to use separate diagnoses (different from the operative diagnosis) and modifiers that indicate that the service provided is unrelated to previous services or procedures (Table 5 ) .

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Table 6. PROCEDURES COMMONLY PERFORMED IN THE CRITICAL CARE SETTING CPT Code

Description:

31500 31600 31603 31622 31645 31646 32020 36489 36600 36620

Intubation, endotracheal, emergency procedure Tracheostomy, planned Tracheostomy, emergency Bronchoscopy, diagnostic Bronchoscopy, therapeutic-initial Bronchoscopy, therapeutic-subsequent Tube thoracostomy, with or without water seal Placement of percutaneous central venous catheter, over age 2 y Arterial puncture, withdrawal of blood for diagnosis Arterial catheterization or cannulation for sampling, monitoring, or transfusion; percutaneous UGI endoscopy w / PEG Diagnostic peritoneal lavage Insertion and placement of flow-directed catheter (e.g., Swan-Ganz) for monitoring purposes Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day Ventilation assist and management; subsequent days

43246 49080 93503 94656 94657

CPT = current procedural terminology; UGI endoscopic gastrostomy.

=

upper gastrointestinal; PEG = percutaneous

Coding and Billing for Procedures

Procedures are documented, coded, and billed much more easily in the critical care setting than E & M services. Common procedures performed in the critical care setting are listed in Table 6. Modifiers apply to procedures and E & M services, and physicians should use these whenever appropriate. In particular, the frequency of central line placement and wire exchanges in critical care makes using the correct modifiers important. Using the -79 modifier to indicate that a central line placement (34689-79) on the second postoperative day was unrelated to the original operative procedure (e.g., a colon resection) is appropriate. Physicians should remember to indicate the diagnosis for which the line was placed (septic shock) and ensure that it is different from the operative diagnosis. Similarly, using modifiers -76 and -77 indicates that the procedure performed was a repeat procedure by the same or another physician. SUMMARY

Optimal conduct of modern-day physician practices involves a thorough understanding and application of the principles of documentation, coding, and billing. Physicians’ role in these activities can no longer be secondary. Surgeons practicing critical care must be well versed in these concepts and their effective application to ensure that they are competitive in an increasingly difficult and demanding environment. Health care policies and regulations continue to evolve, mandating constant education of practicing physicians and their staffs and surgical residents who also will have to function in this environment. Close, collaborative relationships between physicians and individuals well versed in the concepts of documentation, coding, and billing are indispensable. Similarly, ongoing educational and review processes (whether internal or consultative

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from outside sources) not only can decrease the possibility of unfavorable outcomes from audit but also will likely enhance practice efficiency and cash flow. A financially viable practice is certainly a prerequisite for a surgical critical care practice to achieve its primary goal of excellence in patient care.

References 1. AMA finds physicians making less money. American Medical News (AMA newsletter), June 7, 1999, p 9 2. American Academy of Procedural Coders Independent Study Program, Module 2,1996, pp 3-3 to 3-4 3. Brett A S New guidelines for coding physician’s services: A step backward. N Engl J Med 339:1705-1708, 1998 4. Desmarias H R The fraud and abuse provisions of the Kassebaum-Kennedy Bill. Bull Am Coll Surg 828-13, 1997 5. Gallagher C The Medicare program. Bull Am Coll Surg 83:12, 1998 6. Health Care Financing Administration: [Available:www.hcfa.gov/medicare/mcarpti. html 7. Health Care Financing Administration: [Available:www.hcfa.gov/medicare/medicare.

html

8. Health Care Financing Administration: [Available:www.hcfa.gov/medicaid/medicaid. html 9. Kassirer JP, Angel1 M: Evaluation and management guidelines: Fatally flawed. N Engl J Med 3391697-1698, 1998

Address reprint requests to Samir M. Fakry, MD Trauma Services Inova Fairfax Hospital 3300 Gallows Road Falls Church, VA 22042