Neurocritical Care Coding for Neurologists

Marc R. Nuwer, MD, PhD, FAAN; Paul M. Vespa, MD, FAAN Neurocritical Care p. 1800-1809 December 2018, Vol.24, No.6 doi: 10.1212/CON.0000000000000667
PRACTICE ISSUES
BROWSE ARTICLES

Coding specifies the work performed when providing patient care. Critical care services mostly use code 99291, and other codes specify additional time and procedures. Current Procedural Terminology defines critically ill as “a high probability of imminent or life-threatening deterioration in the patient’s condition,” a condition necessary for use of the critical care code. A patient may be critically ill for neurologic reasons even when stable from a cardiorespiratory status. Rules govern who can use these codes, whether they can be used by more than one physician, the locations where the code may be used, and what services are included and excluded. Physicians need to document the medical necessity of visits and nature of critical illness or high-risk medical decision making because auditors may not understand the nature of serious neurologic illness.

Address correspondence to Dr Marc R. Nuwer, University of California Los Angeles, Department of Neurology, Room 1190, Reed Neurological Research Center, 710 Westwood Plaza, Los Angeles, CA 90095, MRN@UCLA.edu.

RELATIONSHIP DISCLOSURE: Dr Nuwer has received personal compensation for serving as an honorary editor for Clinical Neurophysiology; for serving on the board of directors of CortiCare, Inc; and for serving on the editorial boards of the Journal of Clinical Neurophysiology and Neurology Clinical Practice. Dr Nuwer receives royalties from Cambridge University Press and has received research/grant funding from the National Institutes of Health, Second Sight, and the United States Army. Dr Nuwer has given expert medicolegal testimony in a court deposition and a court hearing. Dr Vespa has received personal compensation as an editor for Critical Care Medicine and Neurocritical Care. Dr Vespa has received personal compensation as a consultant for Sage Therapeutics, has received research/grant support from the National Institutes of Health, and holds stock options in InTouch Health.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Drs Nuwer and Vespa report no disclosures.

INTRODUCTION

Physicians, carriers, hospitals, and regulators use the Current Procedural Terminology (CPT) codes to accurately identify and report their services. The American Medical Association owns, maintains, and copyrights the CPT and updates it annually. Use of the correct standardized code set allows physicians, carriers, hospitals, coders, patients, and their representatives to know what services were provided. Codes are available for daily visits as well as for procedures provided in the intensive care unit (ICU). The same codes are used either in a neurocritical care unit or in any other ICU.

EVALUATION AND MANAGEMENT CODING

Use of the critical care daily visit Evaluation and Management code 99291 depends on the severity of illness. Coding policies specify what services should be coded separately, whose services may be counted as critical care, and how to count the time spent providing critical care.

Determining If Patients Are Critically Ill

To use the critical care visit code 99291 (first 30 to 74 minutes), the patient must be critically ill, which must be documented and explained. The phrase critically ill indicates “a high probability of imminent or life-threatening deterioration in the patient’s condition.” The decision making and treatment must include an indication that the patient’s condition met that definition as well as considerations and plans to prevent life-threatening deterioration or organ system failure.

The threat of central nervous system failure alone can require critical care services even without risk of cardiorespiratory collapse. Brain instability or risk of “brain collapse” is as grave a risk to death and quality of life as cardiorespiratory collapse. The following is a list of the commonly encountered neurologic disorders that often justify use of critical care codes:

  • Acute spinal cord compression or injury
  • Acute stroke
  • Coma after cardiac arrest
  • Coma of unknown etiology
  • Guillain-Barré syndrome
  • Intracerebral hemorrhage
  • Malignant intracranial pressure
  • Meningoencephalitis
  • Myasthenic crisis
  • Neuroleptic malignant syndrome
  • Paraneoplastic encephalitis
  • Status epilepticus
  • Subarachnoid hemorrhage
  • Traumatic brain injury

Some patients in the ICU are not critical, such as a patient who is simply on a respirator. For those cases, use other hospital visit codes. Consulting on a patient who is critically ill is not necessarily a critical care service (eg, consulting for altered mental state on a patient in the medical ICU).

The patient’s location is not key. A patient may be in the emergency department or still on a floor unit and yet be critically ill by the definition given above. The neurologist may code for critical care if the patient is critically ill and the neurologist is treating the critical illness. The use of the critical illness code is dependent on the patient’s critical illness and the physician’s actions to address the illness. If the neurologist consults for a minor problem on a patient critically ill for medical reasons in a medical ICU, then that consultation is routine (ie, not critical care).

Who Can Code for the Service

Different specialties may use critical care codes on the same day as long as they are not used at the same time of day. The neurologist should use the diagnosis code for the diagnosis he or she addresses, which may be different from other reasons for being in the ICU. By using different diagnoses than other providers seeing the patient, the physician may avoid denials by avoiding the perception that multiple concurrent physicians are serving duplicate roles.

Only one neurologist may submit critical care code 99291 on a particular calendar date. That neurologist must have documented at least 30 minutes of critical care time. Additional time beyond that may be aggregated together with a second neurologist from the same practice group (ie, one physician may code for the sum of time of both physicians). Or, the additional time may be separately submitted by the second neurologist with code 99292 (each additional 30 minutes of critical care). A physician may not aggregate time with nonphysician practitioners or residents.

A nurse practitioner, as a nonphysician practitioner, may code for critical care if that is within his or her scope of practice. A nonphysician practitioner’s time is counted separately from that of any physician. The nonphysician practitioner’s time cannot be added into the physician’s time when counting time for patients with Medicare (ie, the split-shared coding method cannot be used).

For example, if a neurointensivist performs 40 minutes of critical care services on a patient, and then a nurse practitioner in the same group performs 35 minutes of additional critical care services on the same patient that day, coding for this same patient on the same day is as follows:

  • 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30 to 74 minutes [under the physician’s name]
  • 99292 each additional 30 minutes (list separately in addition to code for primary service) [under the nurse practitioner’s name]
    • CPT © 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Rules for physician assistants vary. Some hospitals, carriers, and states allow physician assistants to code similar to nurse practitioners for critical care, and others are more restrictive. Some states, hospitals, and carriers combine nurse practitioners and physician assistants under the term nonphysician practitioner.

Documenting Time

Code for the total time the patient received critical care. Include the time spent on the patient’s unit reviewing test results or imaging studies, time spent discussing the patient’s case with other medical staff, and time spent documenting critical care services. Also include the time spent caring for the patient in the emergency department or in the radiology department while the patient is in radiology. Activities off the unit away from the patient may not be reported as critical care time because the physician is not immediately available to the patient.

Use CPT codes 99291 and 99292 together to report total time. Code 99291 covers the initial 30 to 74 minutes on that day. Code 99292 covers the additional 30-minute time increments. Use 99292 when time totals 75 minutes or more. When using 99292, documentation should show why time was needed beyond the first hour. A resident’s time and teaching sessions with residents do not count toward billing or coding. Coded time is considered the attending physician’s time spent providing patient care. The following is a summary of neurocritical care coding guidelines:

  • No split-shared services allowed; cannot add together physician plus nonphysician practitioner time
  • Only one provider can code at any specific time of day
  • Document the time spent on the unit dealing with patient’s care
  • Time can be continuous or intermittent and aggregated for that day
  • Must meet minimum time requirements
  • Billing provider’s time counts, not resident’s
  • Critical care is based on the patient’s condition
  • Location is where the patient is, which could be in the ICU or anywhere else

Family Discussions

Providing routine updates to the family also does not count toward billable time spent caring for a patient. Time with a surrogate decision maker can count as critical care time if the patient is unable to give a history or make decisions. Document the discussion as necessary to determine treatment decisions, preferably summarizing the conclusions or options discussed.

PROCEDURES AND OTHER SPECIAL CODES

Procedures bundled into CPT codes 99291 and 99292 that do not require separate coding include the following:

  • Blood draw for specimens including for blood gases
  • Gastric intubation
  • Information data stored in computers (eg, ECGs)
  • Interpretation of cardiac output measurements
  • Interpretation of chest x-rays
  • Pulse oximetry
  • Temporary transcutaneous pacing
  • Ventilator management
  • Vascular access procedures

Include time spent performing these services in the total critical care time. Other procedure codes may be coded separately (eg, lumbar puncture, endotracheal intubation, placement of a flow-directed catheter, cardiopulmonary resuscitation, placement of a ventricular catheter, interpretation of an EEG, or performance of nerve conduction studies). Exclude the time spent providing these procedures from the total critical care time. When performing these other procedures, use modifier 25 with the critical care codes to indicate that procedures and evaluation and management were performed on the same day.

Lumbar puncture has three different CPT codes. One code is for simple CSF drainage, such as may be performed for idiopathic intracranial hypertension. Another code is for blood patch for a CSF leak. The three CPT codes are:

  • 62270 Spinal puncture, lumbar, diagnostic
  • 62272 Spinal puncture, therapeutic, for drainage of CSF (by needle or catheter)
  • 62273 Injection, epidural, of blood or clot patch
    • CPT © 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

The physician may code separately for neurodiagnostic and monitoring procedures for EMG, nerve conduction studies, and EEG. Specific coding advice for these procedures is beyond the scope of this article. The following monitoring and emergency procedures also are among those commonly coded separately in the critical care unit:

  • 31500 Intubation, endotracheal, emergency procedure
  • 93503 Insertion and placement of flow-directed catheter (eg, Swan-Ganz) for monitoring purposes
  • 92950 Cardiopulmonary resuscitation (eg, in cardiac arrest)
    • CPT © 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

End-of-life care planning is important for patients, which is apparent for many patients who are admitted to the ICU. To encourage discussion and preparation of advance care plans, two CPT codes (listed below) allow for coding of the time spent in these discussions. However, the same physician cannot code these on the same day as he or she uses CPT code 99291. These codes may be used on a separate day, such as by the nurse practitioner prior to surgery. While the codes are often used in office practice, they can be used when providing initial or subsequent day evaluation and management (eg, code 99233 for subsequent hospital care per day).

Examples of written advance directives include such forms as the health care proxy, the durable power of attorney for health care, the living will, and medical orders for life-sustaining treatment. The two CPT codes for time spent in discussion and preparation of these forms are:

  • 99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
  • 99498 each additional 30 minutes (list separately in addition to code for primary procedure)
    • CPT © 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Prolonged services are used occasionally in the ICU, but they are not used with the primary codes 99291 and 99292. When a patient is no longer critically ill, the daily visit should be coded as subsequent day hospital management (eg, 99233). The base time for this code is 35 minutes. When the unit time spent for that patient exceeds the base time by more than 30 minutes, then the physician may add a prolonged service code to identify the additional time spent. For example, if the patient is no longer critically ill but requires 80 minutes of documented attending physician unit time, then code 99233 plus 99356. The inpatient prolonged service CPT codes are:

  • 99356 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for Evaluation and Management service)
  • 99357 each additional 30 minutes (list separately in addition to code for prolonged service)
    • CPT © 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Telemedicine

Consultations over the Internet are now more common than they were a few years ago. Many commercial payers are required by states to reimburse for telemedicine. Payers often cover general telemedicine regardless of mandates because of cost savings by preventing emergency department visits and better management of chronic conditions.

For most carriers, the majority of telemedicine is coded using the standard CPT codes plus a modifier. In January 2017, the modifier of choice changed from GT to 95, although some carriers still prefer to use the old GT modifier. Modifier 95 identifies a “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.” For routine inpatient and outpatient teleneurology visits, append the modifier to the same CPT code that otherwise would have been used for that visit. The same documentation standards apply in those cases, which does limit or preclude some codes that require extensive physical examinations.

The CPT Appendix P lists codes for which the telemedicine modifier may be used. The list includes the usual inpatient and outpatient Evaluation and Management codes, but not the critical care codes 99291 and 99292. Instead, CPT specifies two codes for telehealth critical care:

  • 0188T Remote real-time interactive video-conferenced critical care, evaluation, and management of the critically ill or critically injured patient; first 30 to 74 minutes
  • 0189T each additional 30 minutes (list separately in addition to code for primary service)
    • CPT © 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

These codes recognize the difference between the critical care services that can be delivered at the bedside with 99291 and the limitation imposed by the distance. Creation of the two separate codes flags telehealth as a distinct service rather than as delivering critical care services at a distance. Use modifier 95 with codes 0188T and 0189T.

When providing telehealth, use Place of Service 02, which is a new place of service code as of January 2017. Some carriers may not yet recognize this new place of service code. These codes cover interactive audio-video telehealth sessions. They do not apply to telephone consultation or management sessions.

Avoid using simple audio-visual communication that is typical for personal communication because of the lack of full Health Insurance Portability and Accountability Act (HIPAA) compliance. The system must allow private, interactive, two-way audio and visual communication. The website telehealth.org/video claims to list platforms that are HIPAA compliant and encrypted. Remember that the physician may need to be licensed in the state where the patient is hospitalized as well as be privileged in that facility.

Medicare is different than most carriers in that Medicare is much more restrictive in which patients are eligible for telehealth. Most patients covered by Medicare Part B are eligible for remote critical care only if they are hospitalized in a rural area, defined by the United States Census Bureau as a county outside of a metropolitan statistical area or in a rural health professional shortage area. Medicare uses different codes for remote critical care. Medicare also makes an exception by covering certain teleconsultations for acute stroke within 4.5 hours of symptom onset. The critical care telehealth codes for patients with Medicare are included in the Healthcare Common Procedure Coding System:

  • G0508 Telehealth consultation, critical care, initial, physicians typically spend 60 minutes communicating with the patient and providers via telehealth
  • G0509 Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth

The physician might provide a telephone consultation directly with a physician who is caring for a patient at a remote hospital. Some carriers and contracts allow payment for this model. These interprofessional telephone or Internet consultations involve the treating attending or primary physician requesting the advice of a physician with specific specialty expertise without the need for face-to-face contact or telehealth directly with the patient. These circumstances include urgent situations where a timely face-to-face service with the consultant may not be feasible (eg, because of distance). The codes may not be used if the consultant has or will see the patient within 14 days. For example, this code is not to arrange for transfer of care. The time for the service may include review of records and images if the time consulting with the primary physician is more than half of the documented time. The code may be used only once per week for the same patient by the same physician. The CPT codes for interprofessional telephone/Internet consultations are as follows:

  • 99446 Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5 to 10 minutes of medical consultative discussion and review
  • 99447 11 to 20 minutes of medical consultative discussion and review
  • 99448 21 to 30 minutes of medical consultative discussion and review
  • 99449 31 minutes or more of medical consultative discussion and review
    • CPT © 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

The policies, reimbursement, and licensing for telemedicine are actively evolving. Over the next few years, these codes and rules may change. There is much interest in expanding telemedicine, so the future of telemedicine seems bright, especially for population-based care plans that emphasize access to specialty care.

CASE

A 28-year-old man was brought to the emergency department for urgent evaluation and management of status epilepticus. Three neurologists who shared a neurology practice worked to provide critical care for this patient. The first neurologist spent 40 minutes in the emergency department assessing and managing this critical patient and initiated therapy to break the status epilepticus. After his seizures stopped for 20 minutes, the patient was moved to the neurocritical care unit.

Subsequently in the neurocritical care unit, the second neurologist continued to assess for imminent risk of continuing status epilepticus and searched for any provoking causes. The second neurologist spent a total of 35 minutes assuring that the patient’s seizures did not recur and that his clinical state did not deteriorate and searched for the cause that provoked the status epilepticus.

The first neurologist documented 40 minutes of critical care time and reported code 99291. The second neurologist documented 35 minutes of critical care time and reported code 99292 for the additional time, noting that their combined time caring for the patient was 75 minutes. The emergency department physician coded critical care time earlier that morning but not simultaneously with the first neurologist.

On the following morning, the second neurologist performed a lumbar puncture and provided critical care to the patient, who had a fever and two seizures overnight. Later that day, a third neurologist took over for the second neurologist and went on to provide additional critical care services. Together they documented 80 minutes of time for their critical care services. The second neurologist coded 62270 separately for the lumbar puncture and excluded the time she took for the lumbar puncture from her critical care time. The second neurologist coded 99291 for the morning services. The third neurologist coded 99292 for his afternoon services. Both neurologists used modifier 25 with the critical care codes to indicate that the lumbar puncture was a separate procedure.

DISCUSSION

This case presents two examples of the use of codes 99291 and 99292 and how practice partners can aggregate their time to meet the 75-minute minimum for use of the two codes. This case shows the codes being used in different locations, shows coding for a procedure separate from the critical care codes, and exemplifies the use of the modifier in that circumstance.

AUDITOR ISSUES

Physicians can avoid typical problems that cause downcoding when audited. Downcoding is when a CPT level of service is changed to a lower level of service. An auditor may change a 99291 code to a 99233 code. The latter code indicates a hospital follow-up visit with a high level of care.

That change might happen when an attending physician’s note uses accurate language in referring to the patient as critically ill with a high probability of imminent or life-threatening deterioration, but a resident’s note on the same day makes such a statement as, “stable and may be transferred to the floor tomorrow.” An auditor will consider that patient stable and therefore no longer critically ill. The team should be consistent in documentation.

Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient’s condition continues to require the level of attention necessary in critical care. However, notes simply cut and pasted day after day are discouraged. Auditors frown upon critical care notes that fail to reflect the work done and thoughts considered on that day. Notes that fail to change over days give the auditor the impression that the patient’s condition is stable, even if that is not true. It is best to tailor notes to the patient’s condition in a given day. Details in the note should show the work accomplished and planned that day.

Consider that auditors may be poorly educated in neurocritical care. The neurocritical care patient is at risk of imminent death due to further brain injury, which can occur unpredictably and rapidly cause multiorgan dysfunction and death. Auditors are trained in cardiorespiratory critical care, and the clinical neurosciences are foreign to many of them.

Physicians may need to walk auditors through the high-risk rationale, although it should be their job to have this knowledge. Emphasis on specific reasons for neuroprotective strategies in critical care such as mechanical ventilation, osmolar therapy, temperature management, and similar interventions may be useful in educating the coders.

Documentation of existing protocols and specific interventions in the physician’s progress notes may be useful. For example, document a 50% risk of imminent stroke or death if that is the case for that patient with new-onset vasospasm. While a physician may prevail when presenting his or her appeal of an auditor’s downcoding, it is best to act proactively to educate the auditors and establish documentation of imminent danger. Avoiding the downcoding in the first place is better than appealing it later.

Auditors may seem ignorant about how high-risk, unstable, and critical such neurocritical care situations are, such as in cases of vasospasm after a subarachnoid hemorrhage or when tapering sedation from a patient who is pharmacologically suppressed to an isoelectric or burst-suppression state to stop status epilepticus. Document the high risk of failure to carefully treat the vasospasm or to promptly identify and treat recurrent or refractory status epilepticus.

This raises the issue of treating the chart rather than treating the patient. The chart becomes a place for educating auditors. The physician’s time documenting critical care services in the medical record may be reported as critical care unit time (eg, time spent documenting the rationale for treatment and management).

CONCLUSION

Coding specifies what work was performed when providing patient care. Code 99291 describes the evaluation and management of patients who are critically ill, which is defined as “a high probability of imminent or life-threatening deterioration in the patient’s condition.” Documentation must clarify that the patient is in a critically ill state so that an auditor can understand the neurologic critical illness. A patient may be critically ill for neurologic reasons even when stable from a cardiorespiratory status. Other codes specify additional time and procedures used in the ICU. Physicians can combine time with other physician practice partners, but not with nonphysician providers or residents. Only one provider can code at any specific moment of time. Time spent on the unit dealing with patient’s care counts toward the critical care codes, and that time can be continuous or intermittent and added together across that day. Location for critical care services is wherever the patient is, which could be in the ICU or elsewhere such as the emergency department.

REFERENCES

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© 2018 American Academy of Neurology.