Critical Care Services

The following article provides background information on critical care, along with tips for correctly documenting and coding this complex medical service. This summary is intended for informational purposes only and is not a substitute for legal coding advice. Coding and documentation rules are subject to individual circumstances and additional restrictions that may not be discussed in this article.

 

Critical Care Definitions:

Critical care is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such as that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or prevent further life threatening deterioration of the patient’s condition.

Examples of vital organ system failure include, but not limited to:

  • Central nervous system,
  • Circulatory failure,
  • Shock,
  • Renal failure,
  • Hepatic failure,
  • Metabolic failure, and/or
  • Respiratory failure

 

Clinical Condition Criterion:

There is a high probability of sudden, clinically significant or life threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently.”

 

Treatment Criterion:

Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.

 

CPT-4 codes and descriptions copyright AMA

Tips for Coding Critical Care:

  • Assign critical care codes once per day, per patient. Consolidate and report time even when care is rendered in intermittent episodes on a given day.
  • Only one physician may bill for a given hour of critical care even if more than one physician is providing care to a critically ill or injured patient.
  • Codes 99291 and 99292 are used to report critical care services provided to patients over the age of 24 months.
    • 99291 is for the first 30 – 74 minutes
    • 99292 is for each additional 30 minutes
  • Do not report critical care codes for services of less than 30 minutes in total duration – use the appropriate E/M code instead.
  • Do not report critical care codes when a patient is in a critical care unit because:
  • No other hospital bed is available
  • Close nursing observation and/or frequent monitoring of vital signs is required, or
  • Hospital rules require certain treatments be provided in critical care unit.

 

Bundled Services:

CPT manual states that the following services are included in all critical care services and should not be billed separately:

  • Cardiac output measurements
  • Chest x-rays
  • Pulse oximetry
  • Blood gases
  • Gastric intubation
  • Temporary transcutaneous pacing
  • Ventilatory management
  • Vascular access procedures.

 

Avoid These Common Mistakes when Coding Critical Care:

  • Full Attention Required - Physician provides services to other patients during time committed to critical care.
  • Reporting Physician Time - Total time not documented in health record.
  • Total Time Less Than Minimum - Critical care reported when documented time is less than 30 minute.
  • Time Not Committed to Care - Time included that is not directly related to patient care.
  • Other Physician Services - More than one physician reports a critical care code
  • Billable Procedures - Time spent on other billable services/procedures is included in total critical care time
  • Bundled Services - Reporting a procedure that is included with critical care management
  • Medically Necessary - Condition does not support critical care service
  • Teaching Physician Rules - Resident or staff time is included in critical care total time

 

Critical Care Documentation Requirements

Documentation for critical care must:

  • Be created by the rendering physician;
  • Include the critical illness or injury and the critical care activities that were performed;
  • State time spent in work directly related to the individual patient’s care (see below); and
  • Describe the patient’s status and treatment for the entire time for which critical care services are billed (even if there is no change in treatment of the patient).

 

Reporting Physician Time

  • Time recorded as critical care may be continuous or interrupted.
  • Critical care time must be documented in the patient’s health record legibly and unequivocally.
  • Critical care time by the physician in addition to face-to-face care may include:
  • Work directly related to critical care of the patient, whether at patient’s bedside or on the floor/unit.
  • Time spent on floor or unit with family members or surrogate decision makers to obtain medical history, review patient condition or prognosis, or discuss treatment or limitations of treatment.

 

Note: Documentation must show the conversation bears directly on the medical decision making process.

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