A guide to using CPT codes in the inpatient setting
By Brett Baker
Q: What services are included in the critical care current procedural terminology (CPT) codes?
A: Although a critical care CPT code is selected according to the amount of time a physician spends providing critical care to a patient, CPT 2000 identifies specific services that are integral to critical care. The following services are included in the reporting of critical care:
- interpretation of cardiac output measurements (CPT 93561, 93562);
- chest X-rays (CPT 71010, 71020);
- blood gases;
- blood draw for specimen (HCPCS G0001);
- information data stored in computers, e.g., ECGs, blood pressures,
- hematologic data (CPT 99090);
- gastric intubation (CPT 91105);
- temporary transvenous pacing (CPT 92953);
- ventilator management (CPT 94656, 94657, 94660, 94662); and
- vascular access procedures (CPT 36000, 36410, 36600).
These services should not be billed separately.
Q: What services does Medicare include in its payment for critical care?
A: In addition to the services specifically identified by CPT, Medicare considers family medical psychotherapy (CPT 90846) and pulse oximetry (CPT 94760, 94762) part of a critical care service. You should also refrain from billing this service separately.
Medicare allows physicians to report any service that is not listed above separately. Time involved performing services that are billed separately may not be counted toward critical care time, however.
Q: What is the Medicare payment policy regarding critical care furnished by a teaching physician?
A: The teaching physician must be present for the entire period of time that is billed as a critical care service. Medicare allows only time spent by the resident and teaching physician together with the beneficiary or the teaching physician alone with the beneficiary to be counted toward critical care time. Medicare prohibits the teaching physician from reporting time residents spend with beneficiaries without a teaching physician present.
For example, Medicare will pay for 35 minutes of critical care services only if the teaching physician is present for the full 35 minutes. A teaching physician who furnishes 35 minutes of critical care, which may or may not involve a resident, should report CPT 99291 (evaluation and management of a critically ill or critically injured patient, first 30-74 minutes).
Q: Do I need to do a comprehensive history and examination for a patient who comes in for an annual examination to be able to report a preventive medicine services code (CPT 99381-99397)?
A: The introductory text to the section on preventive medicine services codes states that a &"comprehensive&" examination covered by preventive medicine services codes 99381-99397 is not synonymous with the "comprehensive" examination required by evaluation and management codes 99201-99350. CPT goes on to state:
"Codes 99381-99397 include counseling/anticipatory guidance/risk-factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination."
As a result, you do not have to provide a comprehensive history and examination when performing a preventive medicine service. Likewise, medical decision-making does not have to be complex, because the service is preventive in nature. The preventive medicine services codes are treated differently than the codes that are intended to indicate treatment for an acute problem or monitor a chronic condition.
Q: When do I use the hospital observation services codes (CPT 99217-99220) vs. the observation or inpatient care services, including admission and discharge services codes (CPT 99234-99236)? What about the hospital discharge services codes, CPT 99238-99239?
A: An observation care discharge service (CPT 99217) is used for patients who were in "observation status" and discharged from the hospital on a day other than the day they were admitted for observation.
Report an initial observation care code (CPT 99218-99220) for encounters with patients while they are in observation status.
Use an observation or inpatient care services (including admission and discharge services) code (CPT 99234-99236) for patients who are admitted to and discharged from observation status or inpatient status on the same day.
Report a hospital discharge services code (CPT 99238-99239) for patients who are discharged from inpatient status on a day other than the day they are admitted.
The following scenarios help illustrate how you should use these codes:
- Scenario one. You decide to keep a patient for observation on a Tuesday. You initiate the observation, supervise the observation care plan and periodically assess the patient. On the following day, you decide the patient is well enough to go home. You discuss the patient's stay, give instructions for ongoing care and prepare discharge records. The patient is released from the hospital altogether. You should report an initial observation care code, CPT 99218-99220 for Tuesday, and an observation care discharge service, CPT 99217, for Wednesday.
- Scenario two. You keep a patient in the hospital for observation on a Tuesday. You perform the same services relating to the initiation of observation status as described in scenario one. Later that day, you determine that the patient is well enough to be released and you furnish the same discharge services described in scenario one. You should report an observation or inpatient care service (including admission and discharge services), CPT 99234-99236, for that day.
- Scenario three. You admit a patient as an inpatient on a Tuesday. You take the patient's history. You provide an examination of the patient that involves some level of medical decision-making (for example, you provide an initial hospital service, CPT 99221-99223). You check on the patient later in the day and decide he or she is well enough to be discharged. You do a final examination of the patient, give instructions for continuing care, prepare discharge records and write the patient a prescription (for example, you provide a hospital discharge service). The patient is discharged from inpatient status on the same date as the admission. You should report an observation or inpatient care service, CPT 99234-99236, for that day.
- Scenario four. You admit a patient as an inpatient on a Tuesday. You provide an initial hospital service as described in scenario three. During your rounds on the following day, you determine the patient has improved enough to be released. You perform the hospital discharge service as described in scenario three. The patient is discharged from inpatient status a day after the admission. You should report an initial inpatient service, CPT 99221-99223, for Tuesday, and a hospital discharge service, CPT 99238-99239, for Wednesday.
Q: How much do Medicare payments for these services vary?
A: Medicare pays a comparable amount for each scenario described above. The reimbursement amounts are as follows (actual reimbursement will vary slightly by geographic region):
- Scenario one. Total reimbursement for CPT 99219 (initial observation care service) and CPT 99217 (observation care discharge service) comes to $182.32.
- Scenarios two and three. Total reimbursement for CPT 99235 (observation or inpatient care service) totals $171.70.
- Scenario four. Total reimbursement for CPT 99222 (initial inpatient service) and CPT 99238 (hospital discharge service) is $182.32.
Brett Baker is a third-party payment specialist in the College's Washington Office. If you have questions on third-party payment or coding issues, call him at 202-261-4533, send a fax to 202-835-0441, or send an e-mail to email@example.com.
Curbside consults for your practice
Are you curious about new forms of patient scheduling, worried about fraud and abuse or need help coding consults? If the answer is yes, try attending a curbside consult at the Center for A Competitive Advantage (CCA) booth in the Exhibit Hall of this year's Annual Session. Practice experts from the College's Washington Office will discuss 14 practice management topics that College members commonly ask about when using CCA's advisory service. These five- to 10-minute talks will be scheduled during Annual Session break periods, lunches and the Exhibit Hall reception.
The CCA's curbside consults provide a great way to meet experts from the Washington Office, ask practice questions and pick up free resource materials. For a schedule of the curbside consults, check the CCA's Web page (www.acponline.org/cca) or look in Annual Session News, which will be distributed on-site at Annual Session.
Editor's Note: Updated version of this column from 2009 is available
This column has proved to be so popular that ACP Internist updated the material for 2009. Read more in the September 2009 issue of ACP Internist.
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