Billing for Procedures in Critical Care

2015 - 2 April – Clinical Controversies
Ritwick Agrawal, MD, MS
In this article, an expert discusses billing for procedures in critical care.

Billing for procedures in critically ill and injured adults is complex and often not fully understood. The following are attempts to simplify billing for procedures. The clinician should carefully consider several elements of the billing process.
The first element is to clearly identify that a significant, separately identifiable procedure has been performed in addition to the evaluation and management (E/M) services. If a provider is billing E/M service(s) (99221-99233 or 99291) in addition to the procedure(s) on the same calendar day, the modifier 25 should be appended (e.g., 99291-25). The medical records must contain separate documentation for E/M services and the procedure(s). Additionally, a statement should clearly note that the time utilized for billing for the E/M visit does not have overlap with the procedure time.

The second element of the billing is to determine whether a procedure can be billed separately or if it is bundled in the critical care E/M services. In other words, if critical care code 99291 has already been used in the same calendar day, bundled services should not be billed separately. Some examples of bundled services are: placement of nasogastric tubes, measurement of arterial blood gas, peripheral vascular access procedures, ventilator management, interpretation of chest imaging, temporary transcutaneous pacing, interpretation of cardiac output measurements, and interpretation of blood gases, as well as interpretation of information stored in the computer and pulse oximetry. (For example: a patient develops significant gastric distension requiring placement of a nasogastric tube for decompression. The nurse was unsuccessful and the physician later successfully inserts it under fluoroscopic guidance. The additional time required for placement of the nasogastric tube may be included in billing for the E/M services.)

The third element is to accurately report a nonbundled procedure. The following are examples of commonly performed procedures in critical care.

36556  Insertion of nontunneled, centrally inserted central venous catheter; age five or older
36620  Arterial catheterization or cannulation for sampling, monitoring or transfusion
93503  Insertion and placement of flow-directed catheter (e.g., Swan-Ganz) for monitoring
76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access site, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (list separately in addition to code for primary procedure)
31500 Intubation, endotracheal, emergency procedure
31622 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)
31624       with bronchoalveolar lavage (BAL)
31623       with brushing or protected brushing
32554 Thoracentesis, needle or catheter, aspiration of pleural space; without imaging guidance
32555       with imaging guidance
32556 Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance
32557       with imaging guidance
92950 Cardiopulmonary resuscitation

Each Current Procedural Terminology (CPT) code must be associated with an International Statistical Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis code. The diagnostic code establishes the medical necessity of the procedure. For example, an emergent endotracheal intubation (31500) may be associated with the diagnosis of acute respiratory failure (518.81).

If there are variations in a procedure (even for the same procedure), the CPT codes sometimes are different. For example, consider CPT codes 36555, 36556, 36580, and 36597, which are all related to central venous catheter placement. Code 36555 is insertion of a nontunneled central venous catheter in a patient younger than five years, while the code for the same procedure in older patients is 36556. Code 36580 should be used if replacement of a central venous catheter is being performed through the same venous access. If a catheter that is already in place migrates to an unsatisfactory position and is sterilely repositioned under fluoroscopic guidance, code 36597 should be used.
Correct use of modifiers should also be taken into consideration. If a procedure is reduced or eliminated (hypothetically, for example, there was difficulty in placing a central line or arterial line), modifier 52 is used. Modifier 53 would be appended if a procedure was terminated due to extenuating circumstances or if the patient’s well-being was threatened (e.g., hypotension, arrhythmia). If bilateral procedures are performed (such as bilateral chest tubes), modifier 50 should be used. If a service is repeated by the same physician or qualified health professional, modifier 76 should be used. (By way of example, a patient had a right internal jugular central venous catheter placed, but it was accidently pulled out due to the patient’s agitation. Another central venous catheter was placed by the same physician on the same calendar day. Modifier 76 could be appended in this instance.) If a service is repeated by another provider, modifier 77 should be used instead.
Knowledge of billing for procedures is important and sometimes confusing. Careful consideration of these elements when coding will lead to more compliant and thorough billing.