Inpatient critical care: When is it ok to question the medical necessity?

While critical care may be easily identifiable within documentation it is not always clear if it is medically necessary. As coders, we are taught not to assume and to code directly from what is present in the note. But as auditors, we need to not only apply the documentation guidelines but go a step further and begin to ‘read between the lines’ to decipher the medical necessity.

Reviewing documentation for medical necessity should be a thought-out process. I have heard coders at times state that a record could not support critical care due to the diagnosis the patient has, which is not a thought-out statement. We are not clinicians and we are not reviewing the medical necessity to go back to a provider and tell them from a clinical perspective that the patient was not critical. By reviewing each portion of the record, we are looking to see if the critical condition of a patient was shown through the documentation. As auditors, it’s important to remember we review what is given to us, but at times it’s the lack of documentation that did not support the code, not the lack of work done by the provider or lower severity of a patient.

I think the area that most coders and auditors struggle with is when a patient is in inpatient status. It is a common error for providers to bill critical care for every subsequent inpatient visit based on the provider’s specialty (e.g. pulmonary, critical care, neurology) and/or the unit that the patient is located in. It is possible for a patient to be in a critical care unit being treated by a pulmonary specialist and critical care not be supported by medical necessity.

Documentation should paint a picture of the patient’s severity. This starts with the history where the patient describes the severity of their condition. When I look at a critical care statement and begin to question the medical necessity the history is the first place I go back to re-review. How does the patient describe the severity of their condition? Are they worsening or improving? Do they struggle to answer the questions? Are they able to answer the questions themselves? Are they conscious?

After reviewing how the patient describes their condition, if they are able, I then focus on the physical exam. Three areas of the exam that are a good indication of the patient’s condition are constitutional, respiratory, and neurology.

Within constitutional look to see how the provider describes the patient’s overall appearance and review the vitals. Does the patient appear to be in distress? Within the vitals is the patient’s oxygen level low (lower than 90%)? Are they hypertensive (higher than 140/90) or hypotensive (lower than 90/60)?

For respiratory look to see if the provider describes the patient’s respiratory effort. Is the patient struggling to breathe? Are they struggling to breathe while speaking? Are they short of breath? Are they currently on oxygen? For neurology look to see is the patient’s mental status is documented. Is the patient disoriented? After reviewing history and exam, begin putting the pieces together and evaluating the described status of the patient with what critical care is. What is critical care? According to CPT guidelines critical care is defined as a critical illness or injury that "acutely 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."

The following areas support the medical necessity of critical care:  

• An imminent threat to life or bodily function that required immediate intervention
• High complexity of decision making to prevent further life-threatening deterioration
• Use of advanced technology to prevent life-threatening deterioration

The following areas do not support the medical necessity of critical care:  

• Daily management of chronic ventilator therapy, unless other critical care services or intervention was required above and beyond the ventilator management
• Patient is now improving and there is no longer an immediate threat to life or bodily function

As an auditor, it helps to familiarize yourself with disease progression. If a patient is stated to be hypotensive what does that mean? What are the potential risks to that patient in that moment? Did you know that extreme hypotension can lead to confusion, trouble breathing, irregular pulses and shock?

When thinking of the critical care definition it does not make sense that an entire hospital stay would support critical care on each of those dates. If it did the patient would not be stable enough to be discharged. A patient may be in critical condition in the beginning of their hospital admission, but as the stay progresses and the patient begins to improve and stabilize critical care will no longer be medically necessary.

Overall when auditing and coding critical care remember that critical care is not driven by the specialty of the provider treating the patient, or the unit of the hospital that the patient is admitted to. Each note stands alone and each subsequent visit during an inpatient stay must support a critical level of care on its own.

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