1. Prolonged and Critical Care Codes
When to bill and what needs to be documented…..

2. Prolonged Care – When? CPT Codes 99354-99357
Used when time of required patient care exceeds normal time guidelines for E/M codes by at least 30 minutes.
Cannot bill second code if <15minutes left after billing for first hour or if <15 minutes left beyond the last 30 minute charge.
Time DOES NOT have to be continuous.

3. Prolonged Codes-Correct E/M
Prolonged care services ARE NOT payable unless they are accompanied by the E/M companion codes.
E/M is chosen based on level of exam, then the prolonged code is calculated.
Can be used on any level E/M, does not have to be the highest code UNLESS you are billing based on time alone!!!
MUST document total time spent with patient
Do not be general, “> 1 hr spent with patient”, be specific, “I spent 65 minutes with patient”

4. What Codes to Use and Documentation
Can be used with Inpatient/Outpatient, initial/established patients, consults/follow ups.
Minutes of Service
Code
Under 30
Not reported separately
30 – 74
99354 (OP) or (IP)
(OP) or (IP)
X 2 (OP) or
X 3 (IP)

5. Standard Times for Outpatient Visits:
New Patients:
Est. Patients:
Consults:
5 min
99211
10 min
99201
99212
15 min
99213
99241
20 min
99202
25 min
99214
30 min
99203
99242
40 min
99215
99243
45 min
99204
60 min
99205
99244
80 min
99245

6. Standard Times for IP Visits:
Admits:
Follow Ups:
Consults:
15 minutes
99231
20 minutes
99251
25 minutes
99232
30 minutes
99221
35 minutes
99233
40 minutes
99252
50 minutes
99222
55 minutes
99253
70 minutes
99223
80 minutes
99254
110 minutes
99255

7. Critical Care Codes:
Definition: Direct delivery of medical care for a critically ill or injured patient.
Acutely impairs one or more vital organ systems, high probability of imminent or life threatening deterioration
Encompasses treatment of “vital organ failure” and “prevention of further life threatening deterioration…”
i.e) CNS failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.
Patient must be critically ill at time of service but does NOT have to be in ICU.

8. Correctly Using Critical Care Codes
Can include all time spent evaluating, providing and managing patient’s care, as long as physician is immediately available to patient.
Physician must devote FULL attention to patient and cannot provide services to any other patient during that time.
Physician’s of same specialty and group are billed as one provider.
Time does not have to be continuous.
Does NOT get reported with an E/M code, unless patient was seen earlier in the day and was not critical at that time!!!!

9. Included in Critical Care Codes:
These Procedures ARE included:
the interpretation of cardiac output measurements (CPT 93561, 93562)
pulse oximetry (CPT 94760, 94761, 94762)
chest x-rays (CPT 71010, 71015, 71020)
blood gases
information data stored in computers (CPT 99090)
gastric intubation (CPT 43752, 91105)
transcutaneous pacing (CPT 92953)
ventilator management (CPT 94656, 94657, 94660, 94662)
vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600)

10. What is NOT included in codes:
CPR – 92950
Endotracheal Intubation – 31500
Central Line – 36556
Cannot include time spent on procedure in calculation for total critical care time.
Cannot include time spent teaching or time spent by the resident in absence of TP.

11. Documenting Critical Care
Physician may refer to resident’s dictation for specific history, findings, and medical assessment
Physician documentation MUST include:
Time spent providing critical care excluding any time spent on separately reported procedures
Statement that patient was critically ill during the time the patient was seen
What made the patient critically ill
Nature of the treatment and management provided

12. How to Use Critical Care Codes
Time:
Codes:
Less than 30 minutes
E/M code, not critical care
30 – 74 minutes
99291
75 – 104 minutes
105 – 134 minutes
X 2
Now let’s look at some examples!!!!

13. Critical Care Example:
Hospitalist A sees the patient on admission, and spends 40 minutes of critical care time with the patient. That evening, hospitalist B from the same group, that is covering, sees the patient for an 35 minutes of critical care. What codes would get billed?
A) Each hospitalist would bill for their initial critical care.
B) Hospitalist A would bill and hospitalist B would bill for follow-up,
C) Hospitalist A would bill and hospitalist B would bill
Answer: C

14. Jeni Smith, CPC (352) 733-0217 j.smith@ufl.edu
Questions?????
Jeni Smith, CPC (352)