Critical care

January 29th, 2009 - Codapedia Editor
Categories:   Coding   Evaluation & Management (E/M)  

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.


Questions, comments?

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.

Latest articles:  (any category)

COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....
Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?
October 10th, 2023 - Aimee Wilcox
When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.
Accurately Reporting Signs and Symptoms with ICD-10-CM Codes
October 5th, 2023 - Aimee Wilcox
Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.
The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin Resistance
September 19th, 2023 - Aimee Wilcox
Diabetes is a chronic disease that just seems to consistently be increasing instead of improving resulting in a constant endeavor by medical researchers to identify causal effects and possible treatments. One underlying or precipitating condition that scientists have identified as a precipitating factor in the development of diabetes is insulin resistance, which is a known metabolic disorder. As data becomes available through claims reporting, additional code options become possible with ICD-10-CM.
Documenting and Reporting Postoperative Visits
September 12th, 2023 - Aimee Wilcox
Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period? 
Understanding Gastroesophageal Reflux Disease and ICD-10-CM Coding
August 22nd, 2023 - Aimee Wilcox
Gastroesophageal reflux disease or GERD for short, is a disease that impacts millions of Americans on a weekly basis. Symptoms are uncomfortable, as are some of the tests used to diagnose it, but understanding the disease, tests, and treatments helps us better understand how to code the disease using ICD-10-CM codes.

Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2023 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association