Q&A: Reducing denials for CPT critical care services with documentation

Q: What documentation criteria are required to report CPT critical care codes 99291-99292?

A: First, you have to document high-complexity medical decision-making (MDM) and that's using whatever methodology is currently put forth in the CPT book. Currently, there is a matrix that involves:

• The number and complexity of problems addressed
• The amount and/or complexity of data to reviewed and analyzed
• The risk of complications and/or morbidity or mortality

That's how we determine MDM. It has to be high-complexity MDM to be considered critical care.

Beyond that, the clinician needs to document how the patient fulfills critical care. The providers simply documenting “chest pain” and trying to bill CPT code 99291 (critical care, E/M of the critically ill or critically injured patient; first 30-74 minutes) is frequently not acceptable for auditors.

There needs to be a story. The clinician needs to document, for example:

• Which organ system was impaired?
• How was it impaired?
• How is there a high probability of imminent or life-threatening deterioration?
• What did they do to assess, manipulate, vital organ system function?
• What did they do to prevent a life-threatening deterioration of the patient's condition?

What auditors want and what's probably the best documentation that a clinician can give is to create a hero story: By jumping out of my chair, rushing to the patient's bedside, starting these medications, and giving this patient this treatment, I save their life. That's what many auditors want to hear.

If a provider says, “Patient was having a heart attack, 30 minutes of critical care. CPT code 99291,” an auditor may look at that and say, “Where's the MDM? Where was the risk to the patient? How are they having a threat?”

Providers need to give more of a story. For example:

The patient came in with severe 10 out of 10 chest pain. Their EKG showed ST changes. I contacted the cath. lab. I emergently called them in. They came into the hospital. I started the patient on all these medications, and we rapidly moved them up from the ED to the cath. lab.

That's a hero story.

The clinicians need to document all those elements to justify the use of CPT code 99291 for an auditor.

If you haven't had the pleasure of meeting an auditor and having to go through a payer denying you all your codes, I can tell you it is not a fun experience. The chart is what coders need to support the code that they are reporting.

The last thing that the provider needs to document is the time engaged in work directly related to the individual patient. Again, of all the codes that we use in the ED, 99291 is one of the few that have a time-based component. The normal ED E/M codes 99281-99285 do not have time as a component of them.

Editor’s note: Hamilton Lempert, MD, FACEP, CEDC, a residency-trained, board-certified emergency physician and certified ED coder, answered this question during the HCPro webinar, “CPT Coding for Emergency Department and Critical Care.” This article originally appeared in JustCoding.