Facility coding guidelines are essential for hospitals to accurately bill for outpatient services, particularly in critical care settings. Understanding these guidelines, especially the Critical Care Coding Guidelines 2021, is crucial for healthcare providers and billing staff. This article delves into the intricacies of facility coding, focusing on critical care code 99291 and related aspects within the framework of Ambulatory Payment Classifications (APCs) and the Outpatient Prospective Payment System (OPPS).
Understanding Facility Coding vs. Professional Coding
It’s important to distinguish between facility and professional coding. Facility coding, used by hospitals, reflects the resources—like nursing and ancillary staff interventions, supplies, and equipment—utilized in patient care. On the other hand, professional coding, used by physicians, is based on the complexity of the physician’s work, including their cognitive effort and procedures performed. This difference means there isn’t a direct correlation between facility and professional codes for the same patient encounter. Hospitals must develop their own facility coding guidelines that reasonably link the intensity of hospital resources to different levels of service.
The Role of APCs in Outpatient Payment
The Centers for Medicare & Medicaid Services (CMS) established the Outpatient Prospective Payment System (OPPS) and Ambulatory Payment Classifications (APCs) to standardize Medicare payments for hospital outpatient services. APCs are the system used to pay facilities for outpatient services under Medicare, similar to how Diagnosis Related Groups (DRGs) are used for inpatient services. These APCs apply specifically to hospitals and do not affect physician payments under the Medicare Physician Fee Schedule. Facility coding, therefore, is directly tied to APC assignment and subsequent reimbursement for hospital outpatient departments, including emergency departments.
Hospital-Specific Guidelines and CMS Requirements
CMS mandates that each hospital create its own facility billing guidelines because there’s no national standard for assigning Evaluation and Management (E&M) code levels for outpatient services. These hospital-specific guidelines must adhere to OPPS principles and meet eleven specific criteria outlined by CMS. Key requirements include that guidelines should:
- Relate the intensity of hospital services to the different levels of effort represented by the codes.
- Be based on facility resources.
- Be clear and easy to use for accurate payment processing.
- Only require documentation that is clinically necessary for patient care.
- Not encourage upcoding or gaming the system.
These guidelines must be designed to ensure fair and accurate billing that reflects the resources hospitals expend in providing patient care.
ACEP Guidelines as a Model for Critical Care Coding
While CMS requires hospital-specific guidelines, organizations like the American College of Emergency Physicians (ACEP) have developed model guidelines that facilities can adapt. The ACEP facility coding model offers a practical approach for assigning visit levels in the Emergency Department (ED). This model categorizes facility codes and corresponding APC levels based on “Possible Interventions” by nursing and ancillary staff. It also provides “Potential Symptoms/Examples” to aid coders, though code assignment is solely based on the interventions performed.
The ACEP model emphasizes interventions by nursing and ancillary staff, not physician interventions, to determine the facility code level. These interventions serve as indicators of the intensity of facility resources used. The guidelines are structured in levels (99281-99285 and Critical Care 99291), with each level associated with specific interventions and potential symptoms.
Deep Dive into Critical Care Code 99291
Critical care coding, specifically code 99291, follows the same logic as the E&M codes 99281-99285 within the ACEP model. A crucial element for facility billing of critical care is the 30-minute time requirement. This means that to bill for critical care (99291), at least 30 minutes of critical care must be documented.
What constitutes critical care interventions? According to the guidelines, the administration and monitoring of IV vasoactive medications is a strong indicator. Examples include drugs like adenosine, dopamine, labetolol, metoprolol, nitroglycerin, norepinephrine, and sodium nitroprusside. These interventions reflect the high intensity of resources and monitoring required for critically ill patients.
Critical Care Definition
Critical care is further defined as involving “decision-making of high complexity to assess, manipulate, and support impairments of ‘one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.'” This encompasses treatments and interventions aimed at preventing further deterioration in conditions such as central nervous system failure, shock, and respiratory failure. Under OPPS, critical care time includes the time spent by physicians and/or hospital staff actively engaged in face-to-face critical care. If multiple staff members are simultaneously involved, the time is counted only once.
Examples of Critical Care Coding
To illustrate the application of critical care coding guidelines, consider these examples adapted from the original ACEP guidelines:
Critical Care Example 1: Status Epilepticus
A 68-year-old male is brought to the ED by EMS experiencing grand mal seizures with minimal recovery time between episodes. ED staff performs multiple diagnostic tests, administers 2 mg of Ativan IV followed by a Dilantin infusion. His blood pressure is critically high (240/140) requiring a sodium nitroprusside IV drip to reduce it to 180/110. A CT scan reveals a cerebral hemorrhage. The patient is transferred to another hospital for neurosurgical care after 45 minutes of documented critical care.
In this scenario, the presence of “Status Epilepticus” and “Cerebral Hemorrhage” in the “Potential Symptoms/Examples” section for Critical Care, along with the intervention of “Multiple parenteral medications requiring constant monitoring” (Dilantin and sodium nitroprusside drips), clearly justifies the assignment of Critical Care code 99291. The documented 45 minutes of critical care time also meets the time requirement.
Critical Care Example 2: Hypotensive Trauma Patient
A 35-year-old female, involved in a high-speed motor vehicle accident, arrives hypotensive and unresponsive. Initial interventions include establishing intravenous access, rapid fluid resuscitation, and placement on a cardiac monitor. She requires immediate endotracheal intubation to secure her airway and is started on vasopressors to support her blood pressure. A trauma team is activated, and multiple surgical specialists are consulted. Over the next hour, she receives continuous hemodynamic monitoring and further interventions to stabilize her condition.
Here, the “Possible Interventions” such as “Major Trauma care/ multiple surgical consultants,” “Endotracheal intubation,” “Ventilator management,” “Arterial line placement,” and “Administration of IV vasoactive meds” all fall under the Critical Care guidelines. Combined with the patient’s critical condition and the activation of a trauma team, critical care code 99291 is appropriately assigned. If critical care extends beyond 74 minutes, and is documented, then subsequent time might be considered for additional critical care coding, though Medicare packaging rules should be consulted.
Discharge Instructions and Their Impact on Coding
While discharge instructions themselves do not directly determine critical care coding, they are relevant to the overall facility coding level, particularly for lower acuity ED visits (99281-99285). The complexity of discharge instructions, as defined by ACEP guidelines, ranges from straightforward to complex and is considered as a “Possible Intervention” at various E&M levels.
- Straightforward: For self-limited conditions requiring minimal home care.
- Simple: Involving over-the-counter medications or simple treatments.
- Moderate: Including prescription medications, limited activity instructions, and review of potential side effects.
- Complex: For multiple prescription medications, home therapies, or patients needing extensive education due to complex conditions or compliance issues.
The level of discharge instructions contributes to the overall intensity of nursing and ancillary staff interventions, which in turn helps determine the appropriate facility E&M code level (99281-99285).
Conclusion
Accurate critical care coding is vital for appropriate hospital reimbursement and reflects the intensity of resources used in treating critically ill patients. Understanding the critical care coding guidelines 2021, particularly within the context of facility billing and APCs, is essential for healthcare financial integrity. Hospitals should develop and regularly review their facility coding guidelines, referencing models like the ACEP guidelines and staying updated with CMS OPPS regulations to ensure accurate and compliant billing practices. Proper application of these guidelines ensures that hospitals are fairly compensated for the critical care services they provide.
| Facility Charge Assignment | ||
|---|---|---|
| Level | Possible Interventions1 | Potential Symptoms/Examples which support the Interventions |
| ICPT 99281 Type A: APC 609 Type B: APC 626 HCPCS: G0380 |
Initial Assessment No medication or treatments Rx refill only, asymptomatic Note for Work or School Wound recheck Booster or follow up immunization, no acute injury Dressing changes (uncomplicated) Suture removal (uncomplicated) Discussion of Discharge Instructions (Straightforward) |
Insect bite (uncomplicated) Read Tb test |
| IICPT 99282 Type A: APC 613 Type B: APC 627 HCPCS: G0381 |
Could include interventions from previous levels, plus any of: Tests by ED Staff (Urine dip, stool hemoccult, Accucheck or Dextrostix) Visual Acuity (Snellen) Obtain clean catch urine Apply ace wrap or sling Prep or assist w/ procedures such as: minor laceration repair, I&D of simple abscess, etc. Discussion of Discharge Instructions (Simple) |
Localized skin rash, lesion, sunburn Minor viral infection Eye discharge- painless Ear Pain Urinary frequency without fever Simple trauma (with no X-rays) |
| IIICPT 99283 Type A: APC 614 Type B: APC 628 HCPCS: G0382 |
Could include interventions from previous levels, plus any of: Receipt of EMS/Ambulance patient Heparin/saline lock(1) Nebulizer treatment Preparation for lab tests described in CPT (80048-87999 codes) Preparation for EKG Preparation for plain X-rays of only 1 area (hand, shoulder, pelvis, etc.) Prescription medications administered PO Foley catheters; In & Out caths C-Spine precautions Fluorescein stain Emesis/ Incontinence care Prep or assist w/procedures such as: joint aspiration/injection, simple fracture care etc. Mental Health-anxious, simple treatment Routine psych medical clearance Limited social worker intervention Post mortem care Direct Admit via ED Discussion of Discharge Instructions (Moderate Complexity) |
Minor trauma (with potential complicating factors) Medical conditions requiring prescription drug management Fever which responds to antipyretics Headache – Hx of, no serial exam Head injury- without neurologic symptoms Eye pain Mild dyspnea -not requiring oxygen |
| IVCPT 99284 Type A: APC 615 Type B: APC 629 HCPCS: G0383 |
Could include interventions from previous levels, plus any of: Preparation for 2 diagnostic tests2: (Labs, EKG, X-ray) Prep for plain X-ray (multiple body areas): C-spine & foot, shoulder & pelvis Prep for special imaging study (CT, MRI, Ultrasound,VQ scans) Cardiac Monitoring (2) Nebulizer treatments Port-a-cath venous access Administration and Monitoring of infusions or parenteral medications (IV, IM, IO, SC) NG/PEG Tube Placement/Replacement Multiple reassessments Prep or assist w/procedures such as: eye irrigation with Morgan lens, bladder irrigation with 3-way foley, pelvic exam, etc. Sexual Assault Exam w/ out specimen collection Psychotic patient; not suicidal Discussion of Discharge Instructions (Complex) |
Blunt/ penetrating trauma- with limited diagnostic testing Headache with nausea/ vomiting Dehydration requiring treatment Vomiting requiring treatment Dyspnea requiring oxygen Respiratory illness relieved with (2) nebulizer treatments Chest Pain–with limited diagnostic testing Abdominal Pain – with limited diagnostic testing Non-menstrual vaginal bleeding Neurologic symptoms – with limited diagnostic testing |
| VCPT 99285 Type A: APC 616 Type B: APC 630 HCPCS: G0384 |
Could include interventions from previous levels, plus any of: Requires frequent monitoring of multiple vital signs (ie. 02 sat, BP, cardiac rhythm, respiratory rate) Preparation for ≥ 3 diagnostic tests2: (Labs, EKG, X-ray) Prep for special imaging study (CT, MRI, Ultrasound, VQ scan) combined with multiple tests or parenteral medication or oral or IV contrast. Administration of Blood Transfusion/Blood Products Oxygen via face mask or NRB Multiple Nebulizer Treatments: (3) or more (if nebulizer is continuous, each 20 minute period is considered treatment) Moderate Sedation Prep or assist with procedures such as: central line insertion, gastric lavage, LP, paracentesis,etc. Cooling or heating blanket Extended Social Worker intervention Sexual Assault Exam w/ specimen collection by ED staff Coordination of hospital admission/ transfer or change in living situation or site Physical/Chemical Restraints; Suicide Watch Critical Care less than 30 minutes |
Blunt/ penetrating trauma requiring multiple diagnostic tests Systemic multi-system medical emergency requiring multiple diagnostics Severe infections requiring IV/IM antibiotics Uncontrolled DM Severe burns Hypothermia New-onset altered mental status Headache (severe): CT and/or LP Chest Pain–multiple diagnostic tests/treatments Respiratory illness–relieved by (3) or more nebulizer treatments Abdominal Pain–multiple diagnostic tests/treatments Major musculoskeletal injury Acute peripheral vascular compromise of extremities Neurologic symptoms – multiple diagnostic tests/treatments Toxic ingestions Mental health problem – suicidal/ homicidal |
| Critical Care – Critical Care can be coded based upon either the provision of any of the listed possible interventions or by satisfying the Critical Care definition. A minimum of 30 minutes of care must be provided. Critical Care Involves decision-making of high complexity to assess, manipulate, and support impairments of “one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” This includes, but is not limited to, “the treatment or prevention of further deterioration of central nervous system failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, post-operative complications or overwhelming infection.” Under OPPS, the time that can be reported as Critical Care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once. | ||
| Possible Interventions | Potential Symptoms/Examples which support the Interventions | |
| CPT 99291 Type A: APC 617 |
Could include interventions from previous levels, plus any or all of: Multiple parenteral medications requiring constant monitoring Provision of any of the following: Major Trauma care/ multiple surgical consultants Chest tube insertion Major burn care Treatment of active chest pain in ACS Administration of IV vasoactive meds (see guidelines) CPR Defibrillation/ Cardioversion Pericardiocentesis Administration of ACLS Drugs in cardiac arrest Therapeutic hypothermia Bi-PAP/ CPAP Endotracheal intubation Cricothyrotomy Ventilator management Arterial line placement Control of major hemorrhage Pacemaker insertion through a Central Line Delivery of baby |
Multiple Trauma; Head Injury with loss of consciousness Burns threatening to life or limb Coma of all etiologies (except hypoglycemic) Shock of all types: septic, cardiogenic, spinal, hypovolemic, anaphylactic Drug Overdose impairing vital functions Life-threatening hyper/ hypo-thermia Thyroid Storm or Addisonian Crisis Cerebral hemorrhage of any type New-onset paralysis Non-hemorrhagic strokes with vital function impairment Status epilepticus Acute Myocardial Infarction Cardiac Arrythmia requiring emergency treatment Aortic Dissection Cardiac Tamponade Aneurysm; thoracic or abdominal — leaking or ruptured Tension Pneumothorax Acute respiratory failure, pulmonary edema, status asthmaticus Pulmonary Embolus Embolus of fat or amniotic fluid Acute renal failure Acute hepatic failure Diabetic Ketoacidosis Lactic Acidosis DIC or other bleeding diatheses – hemophilia, ITP, TTP, leukemia, aplastic anemia Major Envenomation by poisonous reptiles |
| CPT 99292 | As above in additional 30 minute increments. Record the TOTAL critical care time. The first 30-74 minutes equal code 99291. If used, additional 30 minute increments (beyond the first 74 minutes) are coded 99292. Medicare does not pay for code 99292 because it is considered packaged into 99291; however the services should be reported as appropriate. | |
| Critical Care with Trauma Team Activation APC 618 G0390 |
In addition to 99291, designated trauma centers may report the Trauma Team Activation code G0390 when a trauma team was activated and all other trauma activation criteria are met. |
Footnote 1: Hospital outpatient therapeutic services and supplies (including visits) must be furnished incident to a physician’s service and under the order of a physician or other qualified practitioner. Services provided by a nurse in response to a standing order do not satisfy this requirement. Since Diagnostic tests do not have to be performed incident to a physician service, they may be coded even if the patient were to leave without being seen by the physician.
Footnote 2: As of 2021, CPT has clarified that a test is defined as a service that has a separate CPT code. Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test. The differentiation between single or multiple unique tests is defined in accordance with the CPT code set.
