Billing for Bedside Procedures - Springer Link

17 Billing for Bedside Procedures Marc J. Shapiro and Mark M. Melendez

■■ INTRODUCTION In the USA, in the year 2000, critical care medicine accounted for 14.4% of inpatient days and 0.56%, or $55.5 billion, of the gross domestic product.1 The act of billing for these services has become an art with all the rules and regulations that must be adhered to in order to get compensated for the work that one does. To have a clear understanding of the billing process, this chapter begins with an introduction into the US billing and reimbursement program and then progresses to the process of cognitive and procedural reimbursement.

M.J. Shapiro (*) Department of Surgery, SUNY – Stony Brook University Medical Center, HSC T-18-040, Stony Brook, NY, 11794-8191, USA e-mail: [email protected]

323 H.L. Frankel and B.P. deBoisblanc (eds.), Bedside Procedures for the Intensivist, DOI 10.1007/978-0-387-79830-1_17, © Springer Science+Business Media, LLC 2010

324 M.J. Shapiro and M.M. Melendez

■■ PATIENT CARE CODES In 1966, the first Current Procedural Terminology (CPT) manual was published by the American Medical Association (AMA). CPT’s intent is to standardize terminology used for billing for procedures and direct patient care. The direct patient care codes are known as evaluation and management, or E/M codes. For each code listed in the manual, which comes out yearly, there is a complete description as well as a designated five-digit code. In addition to administrating the CPT process, the AMA also administrates the Relative Update Commission (RUC), a diverse group that maintains a ResourceBased Relative Value System (RBRVS), which establishes the relative value units (RVUs) that CPT codes represent and determines the payment that the health care provider receives. The total RVU value is made of three parts: ●● ●● ●●

The work RVU, which represents 55% of the total The malpractice RVU, which represents about 3% The practice expense RVU, which represents about 42% of the total RVU

There is also a controversial conversion factor (the sustainable growth rate) and a geographic Practice Cost Index, which factors into this payment. This system is used by the Centers for Medicare and Medicaid Services (CMS) and most major health insurance providers.2

■■ CRITICAL CARE CODES Critical care is “the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient.”3 This critical condition is defined by a preeminent or life-threatening condition that occurs to one or more organ systems, impairing the health of that individual by potentially or actually placing them in a life-threatening situation. Although accounting for 30% of all inpatient health care expenditures, critical care medicine involves taking care of the “sickest of the sick,” using the most advanced state-of-the-art technology for diagnosis and treatment. “Critical care involves high complexity decision-making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.”3 The intense acuity and the high level of competence involved in complex and intricate decision making make this aspect not only one of the most fiscally rewarded cognitive areas but also the most challenging for the clinician. Billing for critical care is a time-based code that applies not only to treating complex severe disease and organ dysfunctional states but also includes the time and manipulation to prevent patients from approaching these critical states. The various vital systems included in evaluation and treatment include, but are not limited to the central nervous system, shock due to neurological, traumatic, circulatory or septic etiologies, circulatory failure, renal failure, hepatic failure, metabolic or toxic failure, and/or respiratory failure. As long as the patient’s condition

17. Billing for Bedside Procedures 325

requires this intricate, detailed and constant vigilance, critical care – when documented – can be provided over multiple days, weeks, or months, even if the life-threatening event has improved or is being aggressively treated to prevent progression. Critical care is most commonly given in an intensive care unit (ICU) such as medical (MICU), surgical (SICU), pediatric (PICU), coronary care unit (CCU), emergency department, respiratory care unit, or any other acute care setting. Critical care is given when the patient exhibits a life-threatening or potentially life-threatening condition. Care of a noncritical nature, even if provided in an ICU setting, is reported with other noncritical care E/M codes. The two primary critical care codes (Table 17-1) are time based. The E/M code 99291 is for the evaluation and management of the critically ill or injured patient for the first 30–74 min in a 24-h period. It can only be used once per given date. If the time is less than 30 min, another code (e.g., 94002 or 94003 for ventilatory management) should be used. The code 99292 is listed separately, added once for each additional 30 min. Thus, 120 min of critical care would be coded 99291 + 99292 × 2. Included within this code and as part of the time are interpretations and performance of: ●● ●● ●● ●● ●●

●● ●● ●● ●●

Cardiac output measurements (93561, 93562) Chest radiographs (71010, 71015, 71020) Pulse oximetry (94760, 94761, 94762) Blood gases Patient information: –– EKGs –– Labs –– Vital signs –– Extensive interpretation of multiple databases Gastric intubation (43752, 91105) Temporary transcutaneous pacing (92953) Ventilatory management (94002–94004, 94660, 94662) Certain vascular access procedures (36000, 36410, 36415, 36540, 36600).

Table 17-1. 99291 and 99292 critical care E/M codes. Code Appropriate E/M codes 99291 × 1 99291 × 1 and 99292 × 1 99291 × 1 and 99292 × 2 99291 × 1 and 99292 × 3 99291 × 1 and 99292 × 4 99291 and 99292 as appropriate (see illustrated reporting examples above)

Total duration of critical care Less than 30 min (less than 30 min) 30–74 min (30 min to 1 h 14 min) 75–104 min (1 h 15 min to 1 h 44 min) 105–134 min (1 h 45 min to 2 h 14 min) 135–164 min (2 h 15 min to 2 h 44 min) 165–194 min (2 h 45 min to 3 h 14 min) 195 min or longer (3 h 15 min, etc.)

99291. Critical care: evaluation and management of the critically ill or critically injured patient; first 30–74 min 99292. Each additional 30 min (list separately in addition to code for primary service)


Any services that are necessary and not included above can be billed separately with the appropriate modifier. Critical care codes 99291 and 99292 are the total time spent in providing critical care in a calendar clock 24-h period of time, even if that time is not continuous. Only one physician may bill for a given hour of critical care, even if more than one physician is providing care to the patient. However, during the time reported the physician must devote their full attention to only that patient. This time may also include time reviewing imaging studies and/or test results as well as discussing care with other medical and nursing staff, posting progress notes, discovering clinical findings, writing orders in the medical record, discussing with family members or surrogate decision makers for purposes of obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment when unable to discuss this with the patient due to incompetence or the patient being clinically unable. Conversation time directly bearing on the management of that patient may also be included. Time spent in teaching sessions with residents may not be counted as critical care time whether conducted on rounds or in other venues. Time spent teaching or by the resident in the absence of the teaching physician is not billable, whereas time spent together directly involved in that particular patient’s care may be counted. To include time in the critical care codes, the clinician must be immediately available to the patient. Thus, telephone calls outside the ICU proximity and time which does not directly impact or contribute to the treatment of the patient cannot be counted as critical care. However, time spent during the transport of a critical patient over 24 months of age from a facility or hospital may be included. For pediatric patients under 24 months of age, codes 99293–99296 should be used.3–6 Documentation is crucial to coding. The adage that if it is not written then it did not occur is particularly true with critical care coding. Notes should document that the critical care provided was time based and be legible and detailed (Fig. 17-1). Proper documentation will support the coding, prevent time-consuming resubmissions, avoid denials, and avoid claims of fraud and abuse.7

■■ MODIFIERS Modifiers are added to the CPT code when there is unusual or additional evaluation, management, and procedures performed on the same patient during various times of their hospital stay. The modifiers most often used with critical care codes2, 3 are: ●●

25: Significant, separate identifiable evaluation and management service by the same physician on the same day of the procedure or other service.


Figure 17-1. Example of a SICU note used to document critical care. Used with permission.

–– Used when, on the same day that a procedure or service is provided (e.g., 99291), the patient’s condition requires a significant and separately identifiable E/M service or procedure above and


Figure 17-1. (continued)

beyond the other service provided or beyond the usual pre and postoperative care associated with the procedure (Table 17-2). –– If any procedure is done that is not already bundled into the critical care codes and cognitive critical care is being provided, the modifier should be used.

17. Billing for Bedside Procedures 329 Table 17-2. Critical care procedure codes for commonly performed procedures.2, 3 CPT code 36620 36556 93503 33210 37620 31500 31622 31645 31624 31600 31502 32421 32551 49080 92950 43752 43246

●●

●●

●●

●●

Procedure Insertion arterial line Insertion nontunneled central line over 5 years old Placement PA catheter Insertion temporary transvenous pacemaker IVC interruption Intubation – emergency, endotracheal Bronchoscopy Bronchoscopy with therapeutic aspiration Bronchoscopy with bronchial-alveolar lavage Tracheostomy Tracheotomy tube change prior to established tract Thoracentesis Tube thoraocostomy Puncture peritoneal cavity Cardiopulmonary resuscitation Placement naso- or oro-gastric tube PEG

–– Failure to use the modifier may lead to payment denial. –– Example: (a) Providing 70 min of critical care (b) Placing a central line for hypotension (c) Coding would be 99291 plus 36556–25 –– Any procedure that is not included in the 99291/99292 coding must not have its time included in the time-based code. 51: Multiple procedures. –– Use when multiple procedures are performed outside of the E/M service at the same session as the first procedure –– Append this modifier to the other procedures. 59: Distinct procedural service. –– Use to indicate that a procedure or service was distinct or independent from other services performed on the same day. –– This will prevent these procedures from bundling into each other such as putting in bilateral chest tubes, where each is reimbursed separately. –– When another modifier is appropriate, it should be used in preference to modifier 59. 76: Repeat procedure by the same physician. –– Use for a repeat procedure or service performed subsequent to the original procedure such as performing therapeutic bronchoscopy three times on the same day. –– Add 76 to the third bronchoscopy (34645, 31646, 31646–76). 77: Repeat procedure by another physician. –– Use for a repeat procedure by another physician such as repeating a therapeutic bronchoscopy on the same patient later in the day. –– Add 77 to the second physician’s bronchoscopy code.


■■ MEDICAID AND MEDICARE Many practice plans negotiate rates with private carriers including rates for critical care. Medicaid is a program established in 1965 and, although funded by state and federal governments jointly, is administered by the state and pays for medical assistance for certain individuals and families with low incomes and resources. The more global federal Medicare program is the single largest provider of healthcare insurance in the USA, accounting for approximately 30% of annual payments to hospitals in 2002. In addition to being the primary program to provide healthcare insurance to the elderly, Medicare also covers disabled individuals and those with end-stage renal disease. In 2003, Medicare covered more than 35 million elders and more than 6 million disabled Americans. Previously administered by the federal Health Care Financing Administration (HCFA), in 2001 it was renamed the Centers for Medicaid and Medicare Services (CMS).8 The two principle parts of Medicare include: ●●

●●

Part A, which pays hospitalization to institutions and healthcare facilities and helps subsidize training programs in the USA. Part B is voluntary and supplemental, covering inpatient and outpatient physician services, outpatient hospital services, ambulatory services and certain medical supplies, and other services for eligible participants. It has been estimated that Medicare pays for more than 50% of all ICU days.

Interestingly, without proper documentation for ICU care, the denial rate for claims tends to be high when compared to other physicians, being 15.7% for the 12-month period ending June 30, 2003. The most common reasons for denials, in addition to absence or deficiency of documentation of critical care delivery, are failure to document time, failure to subtract procedure time, and failure to use modifiers after E/M codes.6, 8 Point of care billing using portable or electronic methods will hopefully improve accuracy and facilitate timely bill submissions, but does not substitute for adequate and timely documentation.9 Such programs as “Pay for Performance” recognize excellence and quality healthcare and lead to premium reimbursement. In contrast, CMS and insurance carriers will soon begin denying payment for certain in-hospital complications, such as pulmonary embolism or surgical wound infections, with a secondary goal of driving up quality care and perhaps competition.10

■■ REFERENCES 1. Halpern NA, Pastores SM, Thaler HT, Greenstein RJ. Critical care medicine use and cost among medicare beneficiaries 1995–2000: major discrepancies between two United States federal Medicare databases. Crit Care Med. 2007;35(3):692–699.


2. Dorman T, Loeb L, Sample G. Evaluation and management codes: from current procedural terminology through relative update commission to Center for Medicare and Medicaid Services. Crit Care Med. 2006;34(suppl 3):S71–S77. 3. American Medical Association (AMA). CPT 2009. Chicago, IL: American Medical Association; 2009:17–18. 4. Mabry C. The global surgical package – let’s get the facts straight. J Trauma. 2008;64(2):385–387. 5. Department of Health and Human Services. Medicare Reimbursement for Critical Care Services. Washington, DC: Office of Inspector General, Department of Health and Human Services; 2001, OEI:05:00:00420. 6. Marinelli AM. Optimizing Critical Care Coding. ATS; 2007. http:// www.thoracic.org. 7. Fakhry SM. Billing, coding, and documentation in the critical care environment. Surg Clin N Am. 2000;80(3):1067–1083. 8. Gerber DR, Bekes CE, Parrillo JE. Economics of critical care: medicare part A versus part B payments. Crit Care Med. 2006;34(suppl 3):S82–S87. 9. Fahy BG. Implementation of a handheld electronic point of care billing system improves efficiency in the critical care unit. J Intensive Care Med. 2007;22(6):374–380. 10. Reed RL, Luchette FA, Esposito TJ, Pyrz K, Gamelli R. Medicare’s global terrorism: where is the pay for performance? J Truama. 2008; 64(2):374–389.