How to code Item 1211 within a 24 Hour Emergency Department setting
- Anton van Schalkwyk (Medical Coding Specialist at SAMA)
(A special thank you to Prof Mike Wells of the Emergency Medicine Society of South Africa for his valuable insights in formulating the latest SAMA Interpretation regarding coding for critical care services in the 24 Hour Emergency Department).
Within a 24 Hour Emergency Department setting patients with a diverse array of illnesses and injuries are being consulted. Some of them are not serious at all, for example flu symptoms and their family doctor is not available at the time. But the primary reason for the existence of 24 Hours Emergency Departments are to save the lives of critically ill and injured patients. Some of these bona fide emergencies may take hours of treatment and stabilisation efforts before the patient may be admitted into hospital or taken into theatre.
What is important, is that the Emergency Department visit codes do not include these lifesaving treatments – some of which would demand the attention of more than one discipline.
Currently there are two ways that the Emergency Specialist or a General Practitioner working in a 24 Hour Emergency Department may code for a visit, depending on the acceptance of codes by the different medical schemes. Some of the medical schemes only accept items 0190-0193 with add-on items for emergency and unscheduled visits for all out-patient visits. Others, among which Discovery Health and Medscheme, accepted 24-hour Emergency Department E/M Services codes (items 7060 to 7064).
In CPT, codes 99291 and 99292 would be used in cases of critical care in the emergency department and would be coded in addition to the Emergency Department Evaluation and Management (E/M) services in cases where the critical care takes more than thirty minutes. These critical care codes are time-based and focuses specifically on the involvement of a medical doctor where critically ill and injured patients are being treated. In the United States, the Centers for Medicare and Medicaid Services (CMS) defines critically ill and injured patients as those who suffer from one or more vital organ failure(s) and if not treated correctly could suffer from life threatening deterioration. This would include critical care in ICU and 24 Hours Emergency Departments.
When considering a coding solution for 24-hour Emergency Doctors, SAMA had to decide on how to implement CPT codes 99291 and 99292 specifically for them. It had to be done in such a way that it would not interfere with High Care or Intensive Care codes 1204 to 1210. Items 1204 to 1210 are not suitable for the Emergency Department setting.
The Medical Doctors’ Coding Manual (MDCM) does not currently have the equivalent to CPT 99291 to 99292 within its coding structures. Previously, use of Item 1211 for such purposes was problematic which left the 24 Hour Emergency Department doctors lacking a legitimate way to code for prolonged critical care attendance. But during 2019 SAMA has worked closely with the Emergency Medicine Society of South Africa (EMSSA) to develop protocols under which item 1211 may be coded to be used in the same way that CPT 99291 with 99292 would be coded within the setting of an emergency department visit. An additional interpretation for MDCM item 1211, directed at practices that provide services within the setting of 24 Hours Emergency Departments was added. At the core of this additional interpretation is an acceptable international coding standard for critical care within the 24 Hours Emergency Department which provides a clinical justification for using item 1211 additionally to visit or E/M codes: It codes the lifesaving efforts by the doctor that is not included in doctor’s visit codes (items 0190 to 0193) or Emergency Department E/M Service codes (items 7060 to 7064).
Of course, in its essence, item 1211 is used to code for cardiopulmonary resuscitation. It is therefore highly recommended that 24 Hour Emergency Department practices use item 1211 for resuscitation efforts, while other critical care should be coded with Rule C (6999).
In order to keep the use of the code within specific clinical guidelines, the EMSSA spelled out very specific guidelines within which item 1211 should be coded additionally with Rule C (item 6999) namely:
It may be used to code for cases where illness or injury is of a high severity. The full clinical basis for use by 24 Hour Emergency Department Specialists and General Practitioners working there, are being spelled out as follows in the interpretation to item 1211: when a patient is presenting illness or injury that has a high severity and potentially poses an immediate significant threat to life or deterioration of physiological function and/or where critical care services encompass both the treatment of vital organ failure and/or detection and prevention of further life-threatening deterioration in the patient’s condition, requiring active treatment and management of a patient’s condition with the doctor’s constant attendance (e.g. in cases where one or more physiological signs such as blood pressure, heart rate, circulatory perfusion, respiratory rate, oxygen saturations or level of consciousness are abnormal to the degree that the constant attention of a medical doctor is required).
CPT provides for the following examples to provide guidance for Emergency Department use if critical care coding (Please remember that these are examples and should not be viewed as the total sum of conditions for which to code for critical care):
- Septic Shock.
- Acute Respiratory Failure (e.g. from Asthma).
- Respiratory failure secondary to pneumocystitis carinii pneumonia in paediatric cases.
- Cardiac Arrest.
- Myocardial Infarction, or patients with a history of previous myocardial infarction, consulted with recurrent sustained ventricular tachycardia.
- Hypovolemic shock secondary to diarrhoea and dehydration.
- Major trauma case with trauma team activation.
The key to successful coding of item 1211 should be a full account of the patient’s diagnosis in ICD-10 and the doctor must be able to motivate the critical care within the clinical boundaries set in the amended interpretation to item 1211. Ideally, at least one of the ICD-10 codes should indicate the nature of the physiological instability.
Funders should in all earnest consider accepting items 7060 to 7064 for 24 Hour Emergency Department Specialists and General Practitioners working in these settings, the reason being that coding correctly for these codes would go hand-in-hand with providing additional intensive care. Items 7060 to 7064 focus their attention on three areas of evaluation and management of patients, with some of the more severe cases requiring an additional critical care coding component:
(a) The history of the patient;
(b) The degree of problem focussed examination;
(c) The complexity of decision making;
(d) The risk associated with the presentation.
The advantage of using item 1211 in the Emergency Department setting for critical care, is that it bundles services together. It, of course, includes resuscitation, intubation (laryngeal as well as gastric), insertion of peripheral infusions, oximetry, gastric lavage, ECG and BP monitoring, ventilation and interpretation of special examinations such as blood tests.
Please note that A-lines, CVP-lines and intercostal drain placements are not included in item 1211 and are coded separately.
Here then is the latest version of Item 1211 and its interpretation as published in the 2020 Medical Doctors’ Coding Manual (MDCM):