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How to Code for Critical Care After Stroke

What is the appropriate CPT (Current Procedural Terminology) code for the administration of tissue plasminogen activator (tPA)?

Critical care CPT codes can be used for managing an unstable, critically ill stroke patient. The progress or admitting note must mention the time spent that day, and should state that the patient is “unstable, critically ill.” We recommend that the phrase be written as an explicit statement in the “Impression.”

The critical care codes do not use bullet points. There are no other criteria for content of the notes, beyond specifying the total time spent and clarifying that the patient is unstable and critically ill.

A stroke patient is unstable and critically ill when there is a high probability of imminent life-threatening deterioration. Many stroke patients meet that criterion. Note that a therapy, such as IV tPA, qualifies for critical care coding when it creates a high risk of a life-threatening intracranial hemorrhage.

Critical care codes are used by physicians who manage the patient. They are not used by consultants. There are two codes: one for the first hour (99291), the other for each additional half-hour (99292). The second code can be used in multiple 30-minute units.

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Dr. Marc Nuwer

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Dr. Bruce Sigsbee

How do we code appropriately when more than one physician is involved in a patient's care?

Sometimes more than one neurologist manages a patient on the same day. For example, covering physicians may rotate at mid-day. One provides care for the first 12 hours and the other for the second 12 hours. If the physicians are from the same group and share the same Medicare provider number, then they should aggregate (add together) their time and bill once. The second shift physician should document in his or her note the total time spent by both physicians, and bill accordingly for the combined time.

Sometimes a neurologist manages the stroke, and another specialist manages a different part of the patient's care at the same time, such as ventilator management by an ICU physician. Both may use the critical care codes.

How does the location of the patient affect the ability to use critical care CPT codes?

These codes can be billed at any location, including the ER, radiology, a floor bed, or the ICU. The time spent must track where the patient is. For example, a physician spends 45 minutes with the patient in the ER evaluating and arranging the admission, then 45 minutes with the patient in radiology completing the exam and reading the imaging as it appears, and another hour with the patient in the ICU organizing management and testing. In that case, all two hours, 30 minutes is billable critical care time.

If the patient is already in the ICU, time does not count toward the total time spent off the floor away from the patient at radiology reviewing images or at the office making phone calls. Time counts only when it is spent on the unit where the patient is.

What if the patient is unable to communicate with the physician?

If a patient cannot speak, the family is expected to speak for the patient. Time then counts toward the total critical care time when it is spent explaining the situation to the family, obtaining additional history, and discussing treatment options. If the patient can communicate personal wishes, then family time counts only if the patient is present.

Is the time a resident or medical student spends with the patient billable?

Time spent by residents or medical students does not count toward total critical care time; only time spent by a billing attending counts.

Can other E&M (Evaluation & Management) codes be billed in conjunction with critical care CPT codes?

Both can be billed if both services were provided. The record should document that the E&M service was separate from the critical care service. Both services must be documented. Particular time spent can be counted for either the E&M or for the Critical Care service, but not for both. In other words, it is possible to bill a consult or subsequent hospital visit and then the critical care codes or just the critical care codes, whichever you think works best for you.