Coder's Corner

32 year old male is brought into the emergency department after high speed motor vehicle crash.

You are the trauma doctor on call leading a team of residents.

He is hemodynamically unstable on arrival and gets intubated by the senior resident. The tube goes in few seconds after you come into the trauma bay.

The team under your supervision places a central line and a femoral a-line.

Despite resuscitation, he remains labile from suspected pelvic fractures. You place and inflate a REBOA catheter and the patient goes to the IR for angio embolization.

You spend about about 70 minutes with the patient in the trauma bay.

The IR attending asks you to help with the case as all his residents are not available. You scrub in and assist with the diagnostic angiogram and embolization. 

You also help direct some of his resuscitation in the IR suite during the same time. The procedure takes another 60 minutes.

How should you code for this encounter?

Can you code for the intubation even though you were only there for the last part?

Is there a special code to account for REBOA in addition to the arterial line?

Can you code for your assistance with an IR procedure if you don't have specific credentials to do it independently? If so, can you code additional critical care time done during that procedure as well?

Thomas Esposito, MD, MPH

Interesting case. We believe that you should not bill for the intubation. For minor procedures (5 minutes or less) the teaching physician must be present for the entire procedure (in this case, preparation and induction). For surgical procedures, the teaching physician need only be there for critical and key portions of the procedure. The physician can bill for the arterial line and central line (36620 and 36556).

There is no specific code for REBOA as yet, but we suggest billing 37244 (embolization) with a 52 modifier (reduced service).

Since IR had no residents available, this would make the trauma surgeon an assistant surgeon and not a co-surgeon. However, embolization codes do not allow modifiers 82 (assistant surgeon) or 62 (co-surgeon), so critical-care time should be billed in this situation.

Finally, we believe that high-level initial hospital care (99223; 3.86 RVU) should be billed along with the appropriate segments of critical care (99291 & 99292; 4.50 RVU and 2.25 RVU respectively) for the overall encounter.

R. Lawrence Reed II, MD, FACS, FCCM

Dr. Esposito has accurately outlined the coding for this encounter. Nevertheless, there are a few points that deserve discussion.

As Dr. Esposito explains, it is generally felt that the attending physician cannot bill for bedside procedures unless the attending is physically present at the bedside for the duration of the procedure (as opposed to procedures performed in the operating room, where the attending need only be present for the “critical portion[s] of the procedure.”) However, this ruling actually only applies to patients insured by the Centers for Medicare and Medicaid Services (CMS). The rationale is that the residents’ salaries are already paid by CMS, which makes it improper for them to bill CMS for their services. An attending billing for a procedure for which a resident is already being paid would represent a duplicate charge. However, there are two unresolved issues with this standard concept.

First, not all patients are covered by CMS. In fact, if a resident performs a bedside procedure on a commercially insured patient without an attending’s physical presence, there is often no bill generated. This actually represents a massive gift to health care insurers nationally, as many of the professional procedural charges performed by unsupervised residents are simply given away. This was first identified in a remarkable publication by the group at the Rider Trauma Center in Miami.¹ (Make sure to read the Editorial Comment at the end of the article.) As best I can tell, most residency programs fail to take advantage of the legitimate bills they could generate for unsupervised procedures.

Second, the lack of the attending’s physical presence during the entire procedure means that he cannot bill for his physician work, which is the major component of the Relative Value Units (RVUs) generated by the procedure, as he was not there to provide the work. The total RVUs for any procedure are comprised of three components that are independently valued: physician work, practice expense, and malpractice expense. For CPT code 31500, the total RVU value is 4.07. This breaks down to 3.0 RVUs for physician work, 0.71 for practice expense, and 0.36 for malpractice. Therefore, if the attending does not bill for the endotracheal intubation, there is no payment for the attending’s practice expense and malpractice expense. However, it should be abundantly clear that those non-work components of CPT 31500 should be separately billable, given that there are practice expense costs incurred in having an attending physician on call 24-7 (i.e., call room, call pay, etc.), and there will be malpractice risks incurred in managing this patient’s airway. For example, if the attending fails to identify a malpositioned tube that leads to complications, the attending will still be named in the lawsuit even though he never billed for the procedure. Conceptually, it should be possible to bill a partial charge for CPT codes in these situations, thereby discounting physician work while not discounting the other components. However, as far as I am aware, there has been no strong movement on the part of physicians toward such a process.

There may be some confusion with respect to billing 99223 with critical care (99291/99292) for providing services on the same day. Usually, only one evaluation and management code can be applied by an individual provider (and his/her partners) per day. However, there is an exception that was defined by CMS in in the August 26, 2011, publication (Transmittal 282: Change Request 7405): “When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical care services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service. Hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.”

In this particular example, however, the patient arrives critically ill, so the critical services cannot be temporally separated from the admission history and physical examination (CPT 99223). In order to bill for both the admission note and the critical care services, it is best that you create two documents, each addressing a different concern. The initial admission history and physical examination document, addressed by the 99223 charge, should contain a comprehensive history, a comprehensive physical examination, and medical decision making of high complexity in order to justify the 99233 charge. In that document, it would be appropriate to indicate the patient’s physical findings and physiologic abnormalities, and the plan would include the goal of providing critical care services as necessary to optimize the patient’s condition and reduce the patient’s risk of organ failure(s) and death. Another document would address the provision of critical care services, specifically addressing those conditions that define the patient as being critically ill (i.e., uncontrolled hemorrhage, hemorrhagic shock, respiratory failure, etc.) with respect to their degree, management, response to treatment, and current plans for further care. In addition, the critical care note should document the total amount of time spent on the provision of the critical care evaluation and management services; this time must exclude the time you spent performing procedures as well as the time spent documenting the initial history and physical exam note (i.e., the time spent on the 99223 activities and note).

I suspect most facilities simply bill the 99223 alone for trauma patients who are critically ill upon arrival. Others may bill the 99291/99292 code set based upon the time involvement without billing the 99223. I also suspect that few bill the 99223 with the 99291/99292 codes, so it will be very important to provide the necessary documentation as described above in order to beat the audit.

Reference:

1. Feinstein AJ, Deckelbaum Dl, Madan AK, Mckenney MG. Unsupervised Procedures by Surgical Trainees: A Windfall for Private Insurance at the Expense of Graduate Medical Education. J Trauma. 2011;70(1):136–139; discussion 139–140.