CRITICAL CARE CODING
What is critical care?
Critical care is the direct delivery of medical care, by a physician(s), for a critically ill or critically injured patient. CMS defines critically ill and injured patients as those who are experiencing one or more vital organ failure(s) and who have a high probability of life threatening deterioration in their condition. Medical Coding Placements
Current Procedural Terminology (CPT) is relatively explicit and detailed in its descriptions of critical care services. It is thus not surprising that provision of critical care is the most highly compensated level of Evaluation and Management (E/M) codes for our specialty.
Three components are required for codes 99291 and 99292: a critical illness, which “…impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition;” critical intervention, involving “…high complexity decision making to assess, manipulate, and support vital organ system failure;” and, time, defined as “…time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit.” In order for critical care services to be coded and billed, documentation to support all three components of the definition must be present in the medical record, accompanied by the physician’s attestation that critical care was provided.
The question of whether compensation for the provision of critical care is adequate and truly reflective of the skill required or the real impact on outcome and cost remains open to some debate. That question aside, it is clear that critical care represents not only the best argument for our specialty’s presence, but also, relatively speaking, our best reimbursed activity
Some examples of vital organ failure include:
§ Central nervous system (i.e., brain, spinal cord).
§ Shock
§ Circulatory failure (i.e., heart, blood vessels)
§ Renal failure (i.e., kidneys)
§ Hepatic failure (i.e., liver)
§ Metabolic failure
§ Respiratory failure (i.e., lungs)
There are three key requirements which must be met for critical care:
§ Time.
§ Medical Necessity/Criticality.
§ Interventions.
Time :
This is a time-based code; the physician must document the total time spent in the care of this patient. The first 30-60 minutes will be billed as code 99291, and subsequent half hours will each be billed as a 99292. The time element is the most commonly missed. Frequently physicians will provide wonderful documentation of their critical care services, but failure to explicitly record the time spent will result in the case reverting to an E/M code. Coders are not allow to infer from the record how much critical care time the patient received.
The time requirement is cumulative, meaning it need not be continuous. So if the patient is in the Department for six hours, but you spent 90 minutes over this time frame devoted to the patient's care, you may bill for 90 minutes of critical care. This does includes time not at the bedside, and explicitly includes activities such as lab review, consultations, family decision-making, and documentation. You do not need to explicitly break down a line-item summary of the activities you engaged in.
A key requirement is that you must be "immediately available" to the patient during this time. For this reason, time spent off the unit cannot be included in CC time. This effectively means that providing prehospital control to EMS cannot count towards the total time.
Criticality :
The time requirement is cumulative, meaning it need not be continuous. So if the patient is in the Department for six hours, but you spent 90 minutes over this time frame devoted to the patient's care, you may bill for 90 minutes of critical care. This does includes time not at the bedside, and explicitly includes activities such as lab review, consultations, family decision-making, and documentation. You do not need to explicitly break down a line-item summary of the activities you engaged in.
A key requirement is that you must be "immediately available" to the patient during this time. For this reason, time spent off the unit cannot be included in CC time. This effectively means that providing prehospital control to EMS cannot count towards the total time.
Criticality :
This is the huge subjective element in CC today, and may represent the greatest opportunity (as well as the greatest risk) for your practice. CPT provides examples of critical care which are intended to represent the "mid-range" of CC services. However, CPT also provides examples of Level 5 E/M cases which appear to meet the definition of critical care as it is currently understood. For example, any patient who experiences acute respiratory or circulatory failure requiring ventilatory support or vasopressors is clearly critical. However, a patient with unstable angina requiring intravenous nitrates, beta blockers, and anticoagulants certainly also meets the definition. Or a patient with a GI bleeds requiring fluids resuscitation and transfusion. For that matter, the current definition of sepsis/SIRS is quite broad, and patients with SIRS, even early SIRS, meet the broad definition of "high probability of deterioration."
The key here is to recognize that criticality extends far beyond the intubated patient to a wide variety of conditions.
Intervention:
The key here is to recognize that criticality extends far beyond the intubated patient to a wide variety of conditions.
Intervention:
In order to fully justify the service you are claiming, it is necessary to have done something for the patient. That may include anything from heroic life-sustaining measures to very simple measures such as crystalloid fluid resuscitation, so long as the criticality requirements are met. The CPT definition clearly includes complex decision-making as meeting this requirement. It is, however, more justifiable when there is a tangible and clearly identifiable intervention was performed which can be said to have averted or treated the patient's actual or potential deterioration.
The practice of medicine, as a business, is a challenging model. You have minimal control over your prices, no ability to parley with your biggest payers (the governmental ones, that is), and limited leverage to contract with commercial payers. In our specialty, you also know that a certain significant but unpredictable fraction of your patients will not be paying you at all, and you have to staff to an expected patient volume, but you have no real ability to control your volume. Compensation for services from all payers is perpetually squeezed downward, and given the narrow focus of our specialty, it is difficult to diversify the business model.
Supporting evidence of criticality which is helpful to highlight in your documentation might include:
· Obvious problems like respiratory failure or circulatory failure.
· Any organ system which has acutely failed (or may fail).
· Significantly abnormal vital signs.
· Shock, even early shock.
· Acidosis.
· Need for interventions such as central venous access, thoracostomy, cardioversion/defibrillation, transfusion of blood products, or the "ACLS" suite of IV medications.
· Multi-system diagnoses (aka, your "Train wrecks") requiring highly complex medical decision-making.
· Trauma patients with serious injuries.
· Patients requiring ICU admission.
In conclusion, emergency physicians should, on the one hand, not undervalue their services and remember to properly submit claims for critical care in all appropriate clinical circumstances. On the other hand, overreaching for critical care services in marginal cases could potentially prove costly.
