Critical care services remain to not only be an area of confusion for providers, coders, and auditors, but also a constant target for the carriers for audit. We can sit back and look at critical care and think of all of the ways the code descriptor and/or use could be better defined to prevent misuse - but at the end of the day, the rules are the rules. So, we will continue to have a back and forth between auditor/coder and provider as to what truly constitutes critical care. I hope to try and help give some good tips and qualifiers to help you in making these decisions and to aide in teaching your providers.
The facts, and just the facts about critical care:
Organ system failure
Details of the critical care service provided
Total time of the critical care encounter
These are the documentation guidelines, if you will, our basic rules of critical care. But give a scenario, and they can quickly become complex. While documenting these elements along with the diagnosis of the encounter are imperative, they are not the only requirements. Today our focus is on demonstrating the need - the medical necessity - for the critical care event.
AMA CPT Guidelines has a statement that pretty well sums up what is needed to answer why the critical care services were needed during today's encounter:
"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 to prevent further life-threatening deterioration of the patient's condition."
Our providers are taught that documentation is a communication tool between providers and therefore documentation speaks clinical, which oftentimes gets lost in translation to non-clinical auditors. However, CMS reminds us that our providers are tasked with painting a portrait of the patient's presenting problem to demonstrate the need for the reported service. Clinical documentation more commonly paints the outline of the portrait, but fails to give us the completed portrait. Critical care is no different as even AMA, in the statement above, is identifying that this code should only be used when there is evidence of high complexity decision making for sustaining life for this patient during this encounter.
It's common to want rules and guidance to know if the coding decision being made is correct, but face it - most of what we review does not have this level of specificity. So, let's look to what we know as the next best option. There is one place in which we can relate high decision making to published guidance, and that would be the table of risk (TOR). Now of course I realize that this was created for E&M services and not to the level of a critical care encounter, but it is possible we could use this as a benchmark to say we would expect the high complexity associated with critical care to, at minimum, supersede the highest level of risk. High risk management options, according to TOR, are emergency or major surgery with identified risk, parenteral controlled substances, intensive drug monitoring for toxicity, and decision not to resuscitate. So, we are looking for the documentation to identify what risk(s) exists that exceeds these options.
The next portion of this statement indicates that these high-level decisions are being made in an effort to assess, manipulate, and support vital system functions.
* Assess would indicate that high complexity was involved in assessing the needed interventions for the patient during this encounter. The examination, review of labs, testing, imaging, and all of the physical work needed to provide critical care.
* Manipulate infers that high complexity decisions were used when creating the active treatment plan for stabilizing the patient. Unfortunately, when a provider is trying to convey manipulation of high complexity in the documentation, this would best be communicated by the provider by documenting their thought process regarding the critical care intervention.
* Support of vital system function indicates our provider is making high risk decisions in the continuation of support of not only the organ system in failure, but all of the other organ systems as well. This, in my humble opinion, is such a subjective element and the one that is more commonly not expressed in documentation in a way in which it conveys critical care. Making the decision to place a patient on a 100% non-rebreather mask is not the same as providing an artificial airway, but it is only a baby step away. The provider needs to identify those high-risk decisions not only for intervention of patients failing, but also for those who still meet critical criteria and support.
All of these work together to help define the medical necessity behind the need to provide the critical care service.
When referring to E&M code selection, CGS Medicare states that medical necessity is a culmination of the provider's mental and physical work involved in treating the patient. However, the documentation must show that mental and physical work, and critical care is quite frankly no different. As seen in the 3 elements above, assess infers more of the physical effort required by the provider, while manipulation and support indicate more of the mental efforts of the provider. That mental effort is not always documented through the course of any encounter, but especially not within a critical care note.
Providers, unfortunately, must embrace that documentation is their testimony to the actual events provided to the patient on that date of service, and it is required that they also testify as to why those services were provided.
It takes both pieces to validate not just critical care, but all services provided to patients.
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
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