Perspectives on Medical Reimbursement
By JR Associates
Reprinted from The Society of Critical Care Medicine
Contributing Authors:
Kim Norton*
Managing Partner, Argenta Advisors
Seattle, Washington, USA
Judy Rosenbloom**
President, JR Associates
Reseda, California, USA
George A. Sample, MD***
Washington Hospital Center
Washington, D.C.
In 2005, the American Heart Association published guidelines (Class IIa and IIb) recommending that “unconscious adult patients with ROSC (return of spontaneous circulation) after out-of-hospital cardiac arrest should be cooled to 32 to 34°C (89.6 to 93.2°F) for 12 to 24 hours when the initial rhythm was ventricular fibrillation (VF) (Class IIa). Similar therapy may be beneficial for patients with non-VF out-of -hospital arrest or for in-hospital arrest Class IIb).” The goal of this cooling is to increase the likelihood of intact neurological survival.
Obtaining reimbursement for this type of cooling has proved confusing; proper coding for hypothermia often is misunderstood, given the different techniques and uses for therapeutic temperature management. This article attempts to clarify proper coding practices, answer frequently asked questions related to coding practices for hypothermia, and explain recent and expected changes for obtaining reimbursement for these procedures.
These most recent changes include the ICD-9 Coordination and Maintenance Committee’s approval of ICD-9 code 780.65 (hypothermia not associated with low environmental temperature. The code will be implemented in October 2008. This is an important development, as it demonstrates how the definition of hypothermia has expanded beyond external temperature-related events such as induced hypothermia. Specifically, this new diagnosis code will help to identify the co-morbidity of hypothermia and will provides a new opportunity for more appropriate reimbursement, subject to precise physician documentation and accurate coding.
Common Questions and Evolving Practice
Should physicians report Current Procedural Terminology (CPT) code 99186 for the induction of hypothermia for sudden cardiac arrest? This code is designated as “incident to” a physician’s service. The Centers for Medicare and Medicaid Services (CMS) defines this as services that are furnished “incident to” a physician’s professional services in his or her office. As a result, this service is not payable when provided in the inpatient facility setting. At the CPT Editorial Panel’s June 2008 meeting, the American Medical Association (AMA), proposed deleting code 99186 (hypothermia – total body), arguing that the code was outdated and rarely used. The final decision is pending.
How can physicians obtain reimbursement for the induction of hypothermia for sudden cardiac arrest patients?
Two techniques are available for the rapid induction of hypothermia immediately after arrival at the hospital for accurate temperature control: regulated surface cooling or intravascular cooling. Induction of hypothermia and subsequent temperature management includes the initial complex assessment by the physician and support of multiple vital systems. The patient is monitored closely for shivering, dysrhythmias, and electrolyte imbalances during hypothermia induction; the patient eventually is gradually rewarmed using a controlled method.
Currently, hypothermia induction and temperature management are not separately reportable by a specific CPT code, as one does not exist that describes this service. However, the additional time and effort associated with temperature management may be captured by reporting CPT critical care codes 99291 (first 30 to 74 minutes) and 99292 (each additional 30 minutes), provided the patient meets CMS’s criteria for being critically ill or injured. CMS recently released a revised payment policy for critical care visits that details the various rules. Because these codes are time based, physicians should document any additional time and work associated with the three phases of hypothermia induction and temperature management as described above. The Medicare national payment for each of these codes is $204.15 and $102.45, respectively. In addition, if hypothermia is being induced via catheter, physicians may bill for catheter insertion via CPT code 36556 (insertion of non-tunneled, centrally inserted central venous catheter for patients age 5 years and older). Note the time to insert the catheter may not be included in the time calculation for the critical care codes. The Medicare national average payment for CPT 36556 is $115.78. (All payment rates are based on the January to June 30, 2008, physician fee schedule and unadjusted national Medicare allowable amounts.)
What procedure code is reported by the hospital for hypothermia induction and temperature management?
The hospital inpatient procedure code for hypothermia is 99.81 (hypothermia – central and local). Because it is atypical for hypothermia to be reported as the primary procedure code, it will have no impact on diagnosis-related group (DRG) assignment. However, reporting the code will help build a profile of cases validating the use of these new technologies for hypothermia induction and temperature management. This process is necessary to help with future reimbursement and rate settings.
In summary, hypothermia services provided in the inpatient hospital setting (where they are most likely to be used) may be reported by hospital facilities, although payment is part of the prospective payment that the facility receives. Physician work associated with hypothermia may be reported with the critical care service codes. Each insurer may handle coding and payment for this code differently. It is prudent to check with insurance carriers to assess their coding recommendation for hypothermia induction and temperature management for sudden cardiac arrest.
References
1. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005;112(suppl 24):IV1-203.
2. CMS Medicare Claims Processing Manual – Transmittal 1548; July 9, 2008. http://www.cms.hhs.gov/transmittals/downloads/R1548CP.pdf. Accessed July 15, 2008.
Disclosures
*Author discloses she is a reimbursement consultant with Alsius.
** Author discloses she is a reimbursement consultant with Medivance, Inc.
*** Author has no disclosures to report.
JR Associates Editor’s Note: To talk in more detail about coding and coverage questions about cardiac or other conditions, contact us anytime at 1-818-344-4380. Or send an email inquiry to us at info@1jra.com.
• Learn more about our comprehensive reimbursement services
• Read more articles by and about our consultants
• Visit our Newsroom for more updates and industry alerts
Image Credit: Wikipedia