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
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) or
99356 + 99357 X 3 (IP)
• Can be used with Inpatient/Outpatient,
initial/established patients, consults/follow ups.
Standard Times for Outpatient Visits:
Time:
New Patients:
5 min
10 min
99201
99241
99202
99214
99203
40 min
99242
99215
45 min
99204
60 min
99205
80 min
99212
99213
25 min
30 min
Consults:
99211
15 min
20 min
Est. Patients:
99243
99244
99245
Standard Times for IP Visits:
Time:
Admits:
15 minutes
Follow Ups:
99231
20 minutes
99251
25 minutes
30 minutes
99232
99221
35 minutes
99233
40 minutes
50 minutes
99252
99222
55 minutes
70 minutes
Consults:
99253
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
How to Use Critical Care Codes
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
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
Questions?????
JENI SMITH, CPC
(352) 733-0217
J.SMITH@UFL.EDU