Case Study Challenge: Check Your CC Knowledge by Studying These Detailed Scenarios

You want clinical critical care examples? You got them here.

The details of critical care coding are difficult to determine without some concrete examples to illustrate 99291 scenarios. So what does a really detailed clinical scenario for critical care look like?

Here are the two medical billing and coding scenarios to throw more light.

The challenge: Look at these case studies and see in case you can get all the codes -- diagnosis (ICD-9) and procedure/service (CPT) -- right:

Scenario 1: Physician Treats CHF

A patient comes to the ED with deteriorating shortness of breath (SOB); the physician observes the patient and discovers high blood pressure and tachycardia. The physician orders a Cardizem drip to control the patient's heart rate; she after that orders labs, a chest x-ray, and an electrocardiogram (EKG).

The physician carries out multiple re-evaluations, interprets both the x-ray and EKG, and diagnoses congestive heart failure as well as atrial fibrillation. Total encounter time is 50 minutes; the EKG interpretation takes the physician four minutes.

Answer: On the claim, you must report the following:

• CPT code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the 46 minutes of critical care;
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99291 to display that the critical care and EKG were distinct services, in case your payer requires it;
• CPT code 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for the EKG;
• ICD-9 code 428.0 (Congestive heart failure, unspecified) appended to 99291 and 93010 to signify the patient's heart failure;
• ICD-9 code 427.31 (Atrial fibrillation) appended to 99291 and 93010 to signify the patient's atrial fibrillation; and
• ICD-9 code 786.05 (Shortness of breath) appended to 99291 and 93010 to signify the patient's symptoms.

Scenario 2: Physician Treats Respiratory Failure

A patient comes to the ED with dyspnea and wheezing; the history portion of the exam discloses the patient has asthma. The physician finds the patient in respiratory distress with retractions as well as accessory muscle use. He then orders labs, a chest x-ray, an EKG, and an ABG (arterial blood gas).

The patient gets three rounds of Albuterol and Atrovent Nebs, and steroids by mouth. The physician carries out multiple re-evaluations, interprets the x-rays, EKG, and ABG. The patient starts having evidently increased difficulty breathing in one of the re-evals, and the physician places the patient on BiPAP (bilevel positive airway pressure). In spite of the BiPAP, the patient's rapid deterioration stays.

The ED physician intubates the patient and then admits him to the intensive care unit (ICU). Final diagnosis is asthma and also acute respiratory failure. The physician documents 110 minutes of encounter time with the patient; the physician spent five minutes on intubation and five minutes interpreting the EKG.

Answer: On this claim, you must report the following ICD-9 codes and CPT codes :

• 99291 (for the first 74 minutes of critical care);
• +99292 (… each additional 30 minutes [List separately in addition to code for primary procedure]) for the remaining 26 minutes of critical care;
• modifier 25 (appended to 99291 and +99292 to show that the critical care and the other procedures were separate services, if the payer requires it);
• 31500 (Intubation, endotrachael, emergency procedure) for the intubation;
• 93010 for the EKG interpretation;
• 518.81 (Acute respiratory failure; appended to 99291, +99292, 31500, and 93010 to represent the patient's respiratory failure)
• 493.90 (Asthma, unspecified; appended to 99291, +99292, 31500, and 93010 to represent the patient's asthma diagnosis)