Question

Assign codes to a patient who received critical care services for a total of 210 minutes on July 15. On this date the patient also underwent an inpatient comprehensive history and examination with medical decision making of high complexity. Enter codes

Answer 1

For the patient who received 210 minutes of critical care, assign one unit of CPT code 99291 and four units of 99292, and include the appropriate E/M service code for the inpatient comprehensive history and examination with high-complexity decision making.

Step-by-step explanation:

To accurately code for the scenario described, you would need to assign the appropriate Current Procedural Terminology (CPT) codes for critical care services and for a comprehensive history and physical examination with high complexity medical decision making. Critical care is time-based, and for a total of 210 minutes of critical care on a single day, you would assign code 99291 for the first 74 minutes and code 99292 for each additional 30 minutes. Specifically, you would report one unit of 99291 and four units of 99292. Additionally, since the patient also underwent an inpatient comprehensive history and examination with high complexity medical decision making, you would assign the Evaluation and Management (E/M) code that reflects this service. Note that certain E/M services may be included in the critical care time and should not be reported separately. The coding professional has to evaluate documentation to ensure there is no double-billing and that the services provided are compliant with critical care billing guidelines.