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July 2009
Vol. 19 No. 7
Practice Management
“Ask the Coder” Answers Critical Care Code Questions and More

Given the inherent subjectivity of picking the most appropriate current procedural terminology (CPT) service code, the answers provided through “Ask the Coder” are provided on an “as is” basis. Readers must use their own independent professional judgment in making coding decisions. The reader assumes all risks in using this information.

Earlier this month, IDSA launched the “Ask the Coder” e-mail portal, a resource to help answer tough coding questions for IDSA members and their staffs. Recent topics have included how to bill properly for critical care and prolonged services.

Medicare data indicate that the prolonged services codes are often underutilized— leading to ID physicians not being paid for the entirety of their work. (See IDSA News article.)

An IDSA member asked, “What are the requirements for using prolonged service codes (99354-99357)?”

Ask the Coder: The use of the current procedural terminology (CPT) codes 99354 through 99357 is dependent on where the service is rendered. In an office setting, you would use CPT codes 99354 and 99355. In an in-patient setting, you would use CPT codes 99356 and 99357. The supporting documentation needs to indicate how much time was spent with the patient and a brief description of what was performed during the visit. The CPT codes are time-based, and the CPT book has a grid, as well as information on the companion evaluation and management (E&M) codes.

Another IDSA member asked, “What are the requirements to bill critical care codes 99291 and 99292?”

Ask the Coder: First, the patient must meet the critical care criteria, which is a critical illness described as impairing one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Second, you must give this one patient constant attention. You may bill 99291 for the first hour, and for each additional 30 minutes spent with the patient you can bill a 99292. It is important to note, if you render critical care in a day, you may not bill any other E&M codes. On the other hand, if you see the patient for a regular visit earlier in the day, and then the patient becomes critical, you may bill critical care for those later services, and the original E&M service will need the -25 modifier (a significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported).  Also, you must document the time in the patient’s chart, and write a brief description indicating your involvement.

Do you have a puzzling billing and coding question? You can submit your questions using the “Ask the Coder” e-mail portal and view additional information about billing and coding by visiting
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