Critical care

Critical care services are services provided to a critically ill patient.  It sounds like a circular definition.doesn't it?  The first requirement for billing critical care is the status or condition of the patient.  Although critical care services are often provided in a criticla care unit, location is not a factor in deciding whether to bill for critical or not.  The first requirement is patient condition.

Typically, the patient is suffering from one or more major organ or system failure.  Examples in the Medicare Claims Processing Manual include respiratory failure, renal failure,or  heart failure.  A patient in septic shock may meet the definition of critical care. The physician documentation, supported by the lab/x-ray/other diagnostic tests and physical exam should confirm that the patient is critically ill, requiring immediate and intensive intervention.

That intensive intervention is the second requirement to bill critical care.  A patient who is hypotensive receiving fluids is not receiving a critical care intervention.  A patient who is hypotensive who is receiving two pressor type drugs to maintain adequate pressure, and has invasive monitoring, such as a CVP line and an aterial pressure line is more likely to pass the test of receiving critical intervtions.  Physician definition of renal failure varies widely.  A patient with an abnormal creatinine being treated with lasix and fluid manipulation probably will not meet the criteria while a patient who needs emergent hemodialysis probably will.  Whether or not the patient is critical and the intervetions are of such an intensity to meet the requirements will depend on reviewing the entire record for the day.  These are examples only and are not meant to be proscriptive.  

Some hospitals require that certain drugs be provided in a critical care unit or progressive step unit.  For example, the hospital may have a policy that a patient in diabetic ketoacidosis requiring an insulin drip must have that drip in the unit.  This does not mean that the patient is critically ill and should be billed with the critical care codes.  Location is not a factor.

•    Document total critical care time per calendar date in the medical record.

•    The patient must be critically ill and receiving treatment for their condition.  Document both.

•    Review the activities that can and cannot be counted in critical care time.

Total Duration of Critical Care    Code(s)

Less than 30 minutes    Other E/M service, such as subsequent hospital visit

30-74 minutes    99291 x 1

75-104 minutes    99291 x 1 and 99292 x 1

105-134 minutes    99291 x 1 and 99292 x 2

135-164 minutes    99291 x 1 and 99292 x 3

165-194 minutes    99291 x 1 and 99292 x 4

In order to bill for critical care the patient’s condition must be critical, critical care must be provided and time must be documented in the medical record.

•    Patient location in the critical care unit is not the determining factor: the condition of the patient is the determining factor

•    Physician must be in attendance on the unit and immediately available to provide care

•    Add the time for multiple visits on a calendar date and bill the total time

•    Bill for covering partners of the same specialty as if they were one physician

•    Bill 99291 only once in a calendar date, use 99292 for each additional 30 minutes.

Include time spent in these services as part of your critical care:

•    Providing service at the patient’s bedside

•    Discussing the patient’s condition with other physicians or other members of the patient’s care team when on the unit and immediately available to the patient

•    Reviewing data related to the patient

•    Performing procedures that are bundled into the payment of critical care (listed below)  Check the CPT® book at the beginning of each year for updates to these codes

•    Discussions with the family ONLY IF the discussion with the family involves obtaining clinically relevant history that the patient is unable to give or discussion with the family required because a family member must make medical decisions for the patient

•    Writing notes in the chart

Services bundled into critical care–do not bill separately: (From the CPT® Book)

•    Interpretation of cardiac output measurements (CPT® 93561,93562)

•    Chest X-rays (71010, 71015, 71020)

•    Blood draw for specimen

•    Data stored in computers (e.g. ECGs, blood pressures, hematologic data) (99090)

•    Gastric intubation (91105, 43752)

•    Pulse oximetry (94760, 94762)

•    Temporary transvenous pacing (92953)

•    Ventilator management (94002-94004, 94660, 94662)

•    Peripheral vascular access procedures (36000, 36410, 36415, 36591, 36660)

According to the CPT® book, any services performed that are not listed above should be reported separately.

A physician may never be paid for an ED visit and critical care in the same calendar date.  CMS recently clarified that only one physician may be paid for critical care for any period of time.  That had previously been a matter of carrier policy.

See the entry regarding Teaching Physicians and Critical Care

See the entry regarding Critical Care and Neonate and Pediatric patients.  There were all new codes for these in 2009.

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