CPR CPT® Code 92950 Explained: How To Bill Code Blue.

This lectures describes issues related to billing CPR CPT® code 92950.  This cardiopulmonary resuscitation code is described in the American Medical Association's CPT® manual under the  cardiovascular services and procedure section, with cardiac arrest as the example for appropriate use.  I am a hospitalist physician with over ten years of clinical experience at a large community based hospital with a large cardiac referral base.  I have extensive experience providing CPR care and related billing issues.   

As any physician  who has ever responded to a code blue knows, interventions in resuscitation can vary greatly.  Hospital teams will call a code blue when urgent need for basic or advanced cardiac and/or pulmonary resuscitation is necessary.  Should all physician encounters during code blue emergencies be billed as  CPT® code 92950?  Should face-to-face physician encounters during rapid response team  interventions always be considered appropriate for billing this code as well?  The answer is no.  To understand when billing for CPR CPT® code 92950 is appropriate, we must understand how CPR is defined. 

DEFINE CPR FOR BILLING 92950


Not all cardiac or pulmonary failure should rise to the level of CPR.  How should we define CPR for the purpose of billing a 92950 CPT® code? As the name implies, CPR implies resuscitation of cardiac and pulmonary organs.  Most hospitals have code blue policies and procedures to respond during situations thought to be immediately life threatening from cardiac or pulmonary collapse.  However, not all code blue episodes require chest compressions.  Some code blue emergencies may involve basic life support (BLS) while others may involve advanced cardiac life support (ACLS).  Code blue response can involve any combination of airway support, intubation, chest compression, medication administration and direct or indirect cardioversion or defibrillation.  CPR for the purposes of billing code 92950 should include  chest compressions.  More can be reviewed here regarding this clarification of the need for chest compressions when billing for code 92950.

What if the patient needs chest compressions but a patient's advanced directives have instructed the medical team not to provide them?  This situation does happen.  Advanced directives may instruct medical teams to provide medication support, ventilation and/or shocks but to withhold guideline driven chest compression to prevent traumatic chest wall injury (broken ribs).  If I respond to a code blue and I believe chest compressions are necessary but we have been instructed not to do them, I will bill critical care codes 99291 and/or  99292 if my documentation supports the use of these codes and I document why chest compressions were not provided.  I would not bill CPT® code 92950 because chest compressions were not provided.  I compare this to patients who decline a recommendation for surgery.  If a patient declines necessary surgery, they shouldn't be billed for a surgery that wasn't done. 

Many hospital systems have emergency crash carts that are unsealed during code blue protocols.  This act initiates a series of charges for the patient or their insurance company.  Breaking the seal on a crash cart involves filling out flow sheets detailing the timing of chest compressions (if given) and medication administration during resuscitation efforts.   If a crash cart has been unsealed during a code blue, should the physician bill for CPR regardless of whether chest compressions were given?  I don't think so.  I believe the threshold to bill for CPR code 92950 is to provide chest compressions.   In fact, one document refers to this scenario detailed in the  National Correct Coding Initiative manual on chapter 11.  The situation involves coding defibrillation without chest compressions during resuscitation efforts.  My interpretation of this document says resuscitation that does not involve chest compressions should not be billed as CPT® 92950. 
"There is no CPT code to report emergency cardiac defibrillation. It is included in cardiopulmonary resuscitation (CPT code 92950). If emergency cardiac defibrillation without cardiopulmonary resuscitation is performed in the emergency department or critical/intensive care unit, the cardiac defibrillation service is not separately reportable."
In other words, if a patient undergoes defibrillation but gets no CPR (chest compressions), this procedure cannot be billed as CPT® 92950 and there is no separate code to use.  I would bill defibrillation without chest compression using critical care codes 99291 and/or 99292 if time thresholds were achieved or other appropriate E/M codes when critical care time thresholds are not achieved. 

 DOCUMENTATION REQUIREMENTS FOR CPR

 

There are no specific documentation criteria for CPR CPT® code 92950 except for the service to be medically necessary.  In addition, I think it's a good idea for chart documentation to indicate CPR was in fact performed.  For a full review of all CPT® codes, review the AMA's CPT® 2015 Standard Edition. How do I handle my code blue documentation?  I always dictate a note but I do so to help other physicians find access to the intervention.  I believe the physician who signs the code blue sheet is indicating their supervision of the resuscitation process and can bill for the service provided, 92950 if chest compressions were provided or a qualifying E/M charge if chest compressions were not administered.  Does the physician actually have to do the chest compressions to get paid for CPT® code 92950?  The answer is no.  As long as the physician is supervising, other members of the team can provide airway and circulation support.  Any physician or qualified non-physician practitioner (NPP) can bill CPR at any site of care. 

What ICD code should be used with CPT® code 92950?  I don't think any specific ICD code is required, as long as the documentation supports the use of that code.  However, ICD code 427.5 is appropriate under all circumstances of CPR.  ICD code 427.5 is used for cardiac arrest.  

CAN MORE THAN ONE PHYSICIAN BILL FOR CPR AT A TIME?


What if a cardiologist and a hospitalist and an  emergency room physician were all present at a code blue requiring chest compressions?  Can all three physicians bill for CPR?   I do not believe more than one physician can bill for CPR code 92950 at the same time.  I could not find any definitive resource to state this fact, however, CMS does not currently allow two physicians to simultaneously bill for critical care at the same time.  Extrapolation of this rule would imply that two physicians present and directing CPR could not both receive payment for the same service at the same time.  When CPR is provided, most hospitals have a time log  detailing when medications and chest compressions where given.  Often, a physician signature is required at the end of the log. If I bill for CPR, I make sure documentation supports myself as the supervising physician.

BILLING CPR AND CRITICAL CARE SCENARIOS ON THE SAME DATE


Can a physician bill for CPR and critical care in the same day?  The answer is yes.  Documentation must indicate that time spent on CPR was separate from time spent during critical care services and a modifier 25 should be used.   The Centers for Medicare & Medicaid Services (CMS) provided guidance for  this situation on page 22 of this document.  They state:
CPR has a global period of 0 days and is not bundled into critical care codes. Therefore, critical care may be billed in addition to CPR if critical care was a significant, separately identifiable service and it was reported with modifier -25. The time spent performing CPR shall be excluded from the determination of the time spent providing critical care. In this instance it must be the physician who performs the resuscitation who bills for this service. Members of a code team must not each bill Medicare Part B for this service.
Once chest compressions are completed and further resuscitation and support is needed, the physician may continue to bill critical care CPT® codes 99291 and/or 99292 if documentation supports their use. Other resuscitation efforts can include management of blood pressure support medication, airway management, other end organ evaluations, discussion with other physician consultants and determining further stabilization efforts.   These ACLS efforts can be billed under the critical care evaluation and management (E/M) codes.  How do I decide when to bill CPT® code 92950 and when to bill critical care, or both?  Here are some scenarios to consider:
  •  You provide CPR lasting less than 30 minutes and  you provide no other E/M service:
    • Bill  CPT® code 92950 alone. 
  • You provide CPR lasting less than 30 minutes on someone plus additional E/M services before or after the CPR effort:
    • Bill for CPR code 92950 and
      • E/M services 30 minutes or more:  Bill critical care codes 99291 and/or 99292.
      • E/M services less than 30 minutes:  Bill appropriate E/M charge based on the site and status of the patient (such as initial hospital encounter or follow up codes).
    • Document CPR time was separate from E/M charge and use modifier 25.
  • You provide CPR lasting greater than 30 minutes and no other E/M charges:
    • Consider billing for critical care instead of for CPR.  Providing CPR would meet the threshold for critical care.  CPT® code 99291 pays more than CPR code 92950.  See below for a discussion of this RVU impact and comparison.   
  • You provide CPR lasting greater than 30 minutes (prolonged CPR) and additional E/M charges:
    • The time used for CPR cannot be billed with the time used for E/M charges.  This scenario can get a little tricky, since CPR care can be billed as critical care codes 99291/99292 or 92950.  In most cases, the physician should bill  for CPR time separately and then bill for the E/M work:
      • If E/M is 30 minutes or more, also bill critical care 99291 and/or 99292 if applicable.
      • If E/M less than 30 minutes, bill appropriate non-critical care E/M charge.
    • Instead of billing for code 92950 and an E/M charge, consider billing CPR and E/M combined as critical care 99291 + 99292 if the CPR + E/M time passed the 75 minute mark and the non CPR E/M visit portion was less than the 30 minute threshold for critical care.    I believe, in some instances, this would pay more than CPR plus a non critical care E/M code if the total time spent lasted 75 minutes or longer.   Consider reviewing the E/M work RVU values for your E/M charge to  find the best paying scenario.  
      • For total combined CPR + E/M time of 75 minutes or more, billing critical care 99291 and 99292 is more likely to be financially beneficial when documentation would only support a hospital follow up code as the E/M charge after CPR and less likely if a high level new patient encounter code could be used.  
        • (CPR + hospital follow up) vs only critical care work RVU analysis
          •  work RVU for 92950 + 99233 = 4 + 2 = 6 wRVU 
          •  work RVU for 99291 + 99292 = 4.5 + 2.25 = 6.75 wRVU 
      • If a new patient encounter code could be used (for example, getting consulted after the code for continued management), billing CPR code 92950 plus an initial hospital encounter code code 99223 or consult code 99255 for non-Medicare patients would pay more than 99291 + 99292 if the non CPR E/M component of the visit lasted less than the 30 minute critical care threshold but the combined CPR + E/M visit lasted 75 minutes or longer. 
        •  (CPR + hospital initial) vs only critical care work RVU analysis
          • work RVU for 92950 + 99223 = 4 + 3.86 = 7.86 wRVU 
          • work RVU for 99291 + 99292 = 4.5 + 2.25 = 6.75 wRVU
  • You provide two or more separate episodes of CPR mixed with two or more separate E/M charges on the same calendar date:
    • Bill each episode of qualifying CPR using CPT® code 92950.  
    • If the total documented time used for E/M face-to-face visits is 30 minutes or more, bill for critical care 99291 and/or 99292.  Remember, critical care time does not have to be continuous.  If you provide two or more pre or post CPR face-to-face evaluations, document and add the time for each visit and use the summation to determine whether or not critical care can be used using 30 minutes as the time threshold. 
    • Make sure to document CPR time as separate from E/M charges and use 25 modifier as well.

 

BILL FOR CPR MORE THAN ONCE PER DAY

 

Can physicians bill for CPR more than once per day? As indicated above, CPR has a global period of zero days. If the service was medically necessary, there is no time frame limiting the use of this code more than once per day. I have in the past billed this code more than once in a day on the same patient and have heard of no problems getting paid for CPR two or three times or more per day. If a physician provided CPR in the morning and again an hour later as a separate and identifiable encounter and again later in the afternoon, payment for multiple 92950 encounters in the same day should be made.  Make sure to document the time performed for these codes as different from other critical care time that may be provided. 

CPR RVU REVIEW


What are the relative value units (RVUs) for CPR and critical care in 2014?  The 2014 RVU conversion factor is $35.8228 per RVU and the 2014 RVU values and associated dollar values in my geographic area are:
  • CPT code 92950
    • work RVU:  4.0
    • total RVU (facility):  5.29;  about $179
    • total RVU (non-facility):  8.52;  about $310
  • Critical care code 99291
    • work RVU: 4.5
    • total RVU (facility):  6.27;  about $212
    • total RVU (non-facility): 7.67; about $257
How often is CPR CPT® code 92950 billed?  Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 92950 encounters were billed and the dollar value of their services for Part B Medicare.   This code was billed 84,452 times in 2011 with allowed charges of $14,874,839.25 and payments of $11,705,849.79.  You can see much more in my free lectures on E/M hospital coding as well as my hospitalist resource center.  


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