Critical care refers to specialized care of patients whose conditions are life-threatening and who require comprehensive care and constant monitoring by a qualified healthcare professional. There are various aspects to coding these services; in fact it is not only about the coding but also about the rules that go along with Critical care. Relying on the services of a reliable medical billing company can help healthcare providers get the task done efficiently. Since there are only two codes for reporting critical care, it would be quite normal to think that reporting this service would be simple or uncomplicated. However, several questions arise when a practitioner starts reporting critical care services. Here are some of the frequently asked questions and answers about critical care services.

Q: What is the CPT definition of critical care service?

A: Critical care service is the direct delivery of medical care to a seriously ill or injured patient. An illness or injury can be termed as critical when it acutely impairs one or more vital organ systems so that there is a high probability of imminent or life-threatening deterioration in the patient’s condition. It involves high-complexity decision-making to assess, manipulate and support vital system functions to treat single or multiple vital organ system failure, or to prevent further life-threatening deterioration of the patient’s condition.

Q: What does the term “critical care must be medically necessary” mean?

A: “Medically necessary” means that the patient needs the medical service because she is critically ill, and her illness or injury can acutely impair one or more vital organ systems so that there is a high probability of imminent or life-threatening deterioration in her condition. According to CMS, critical care must be a service that encompasses both treatment of “vital organ failure” and “prevention of further life-threatening deterioration of the patient’s condition”. Examples of vital organ failure include, but are not limited to, central nervous system failure, circulatory failure, renal, metabolic, shock, hepatic or respiratory failure.

Q: What are the specific areas where CCU services are provided?

A: Generally, critical care services are provided in areas such as the coronary care unit, emergency care unit, respiratory care unit and intensive care unit (ICU).

Q: Which specialists manage critically ill patients?

A: Critically ill patients are managed by specialists such as critical care physicians (intensivists), physical therapists, palliative care specialists, respiratory therapists, mid-level practitioners, nutritionists and pharmacists. These specialists must report their services with the correct diagnostic and procedural codes to receive appropriate reimbursement.

Q: Does a patient who has a potential for further deterioration or one who is on ventilator, but with stable condition qualify for critical care?
A: A patient on ventilator may not be considered critical unless she meets the specific critical care definition (even if she is being managed in the intensive care unit). A patient who has undergone a surgery and is placed in intensive care for constant observation may not come under the definition of critical care, if there isn’t a potential life-threatening deterioration. Therefore, correct understanding of what constitutes critical care services is crucial in reporting the services accurately. Here, physicians can benefit from medical billing services provided by a reliable vendor.

Q: What are the guidelines for critical care documentation?

A: Critical care is a time-based service and the medical billing for these services primarily depends on the total time Spent on managing, evaluating and providing quality medical support to the patient. The time does not necessarily need to be continuous, but it cannot include the time not devoted towards patient attention.

Q: What should critical care documentation include?

A: Critical care documentation should include the following –

• The organ system(s) at risk
• Course of treatment (plan of care)
• Critical findings of laboratory tests, imaging, ECG, etc., and their significance
• Which diagnostic and/or therapeutic interventions were performed
• Likelihood of life-threatening deterioration without intervention

Typically, a patient who is in a critical stage will have a lot of other comorbid conditions. When coding for these services, it is essential for physicians to code and report the patient’s comorbid conditions or underlying conditions even if they are managing only one specific condition.

Q: How is physician time measured for the purpose of determining the correct critical care code(s)?

A: When a patient is admitted to critical care, the time spent towards the following activities will be considered or documented as critical care time –

• Time spent for bedside procedures with the patient
• Time spent on activities related to patient attention and observation (including review of old medical records, physical examination, lab and imaging results and consulting with other physicians)
• Discussions with the family (involves obtaining history that the patient is unable to give or discussion with the family required because a family member must make appropriate medical decisions for the patient)
• Time spent for writing or dictating notes in the chart or electronic health record
• Time spent towards reviewing diagnostic tests and data related to the patient

For all subsequent visits (whether on the same date or different date) the documentation should reflect the critical status of the patient, a physical examination, change in treatment plans and labs or other bedside procedures. The total time spent should be documented for each CCU encounter and the codes billed should reflect the total time spent on the date of service.

Q:  What CPT codes are used for reporting critical care services?

A: Adult critical care is a time-based service and is reported for all patients who are critically ill and above the age of 5 years. On the other hand, if the patient is below 5 years, the neonatal or pediatric critical care codes will be reported. Physicians while billing for CCU services must use the following CPT codes –

• 99291 – Critical care, evaluation & management, first 30 – 74 minutes
• 99292 – Critical care, each additional 30 minutes

As per CPT guidelines, if the patient is managed less than 30 minutes in a calendar day, the following codes will be reported –

• 99232 or 99233 or other appropriate E/M code – less than 30 minutes duration

Q: Which services are bundled into the critical care code (as per CPT guidelines)?

A: There are several services that are often included in “critical care clock” time, but can’t be billed separately. However, the time spent on these services is counted towards total CC time and these include –

• Gastric intubation – (CPT 43752, 43753, 91105)
• Ventilator management – (CPT 94002-94004, 94660, 94662)
• Transcutaneous pacing – (CPT 92953)
• Pulse oximetry – (CPT 94760, 94761, 94762)
• Peripheral vascular access procedures – (CPT 36000, 36410, 36415, 36591, 36600)
• Interpretation of cardiac output measurements – (CPT 93561, 93562)
• Chest x-rays, professional component – (CPT 71010, 71015, 71020)
• Blood gases, and information data stored in computers (like ECGs, blood pressures, hematologic data) – (CPT 99090)

Q: Is immediate availability of a practitioner to the patient important to report CCU services?

A: Yes, the healthcare practitioner must be immediately available to the patient to report this service. This service will not give the practitioner the freedom to remain at home and discuss the patient’s condition with another physician in the ICU. Critical care service does not need to be continuous, but can be intermittent and can be provided at various times during the calendar date of the service.

Q: What are the procedures that could be billed separately from critical care?

A: Some of the common procedures that may be reported separately for a seriously ill or injured patient include (but are not limited to) –

• Temporary transvenous pacemaker (33210)
• Intraosseous placement (36680)
• Endotracheal intubation (31500)
• Electrocardiogram – routine ECG with at least 12 leads; interpretation and report only (93010)
• Elective electrical cardio version (92960)
• CPR (92950) (while being performed)
• Central line placement (36555, 36556)

Q: How can practitioners bill for their critical care service during a specific time period?

A: Even if more than one physician/practitioner is managing a critical patient, only one person can bill for the service during a specific period of time. For instance, if a cardiologist and a pulmonologist are taking care of a patient from 10:00 -11:00 am, only one person can bill for that individual time frame. On the other hand, if the cardiologist is managing the critical portion from 1- 2 pm and the pulmonologist manages his portion of service from 2.30-3.30 pm, both of them can bill for their services as long as they are managing different conditions. Diagnosis lays a crucial role in differentiating that they are managing two separate problems.

Q: What are the services that may not be included in critical care time?

A: Services that may not be included in critical care time include –

• Updating family members who are not making medical decisions
• Time spent off the unit not providing care directly related to the patient
• Teaching time with interns, residents and other providers
• Researching the patient’s condition
• Time spent for performing procedures for which a separate charge is made
• Time spent in typical follow up for all patients
• Time spent caring for other patients either in the unit or in another area of the hospital
• For Medicare patients, time spent in caring for complications that are related to a procedure

Coding for critical care services can be challenging. Proper understanding about what meets the medical necessity requirement is crucial when reporting this service. Relying on critical care medical billing and coding services provided by a reputable outsourcing company can help providers avoid claim denials and ensure optimal reimbursement.

Disclaimer: The information provided in the above content has been obtained from various internet resources, and is for informational purposes only. OSI (Outsource Strategies International) cannot guarantee that the information contained in the above FAQ is in every respect accurate, complete, or up-to-date. Payment policies may vary from one payer to another and OSI assumes no responsibility for, and disclaim liability for damages of any kind, arising out of or relating to any use, non-use, interpretation of, or reliance on the information contained in this FAQ.

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