Prolonged and critical care codes
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Prolonged and Critical Care Codes. When 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.

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Prolonged and Critical Care Codes

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Prolonged and Critical Care Codes

When 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.

Standard Times for Outpatient Visits:

Standard Times for IP Visits:

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 immediatelyavailable 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

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) [email protected]

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