Medicare, Medicaid and many insurance company auditors often challenge the accuracy of a physician's billing of critical care services. To avoid rejection of critical care codes, physicians must be familiar with coding definitions, and documentation must reflect the professional services that support the codes. Critical care treatment falls under Evaluation and Management (E&M) services billed with codes 99291 and 99292. Services billed with these codes must meet the following criteria
- The patient must have 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.
- Just because a patient is critically ill or injured, and/or is in the ICU/CCU, doesn't mean his care is automatically a critical care service. Critical care codes represent an intensity of care that is greater than standard E&M codes. The care must involve highly complex decision making that is necessary to assess, manipulate and support vital system functions to treat vital organ failure (shock, renal/hepatic/respiratory failure, etc.), and/or prevent further life-threatening deterioration of the patient's condition.
Codes not contingent on site of service
Critical care codes are based on a patient's condition and the intensity of services provided, not on the site of the service. Thus, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care. Although usually provided in a CCU or ICU, critical care services can be provided in an ED, a non-ICU hospital room, a clinic or a parking lot.
The following situations would not necessarily warrant billing of critical care services
- Daily management of a patient on chronic ventilator therapy,
- Management of dialysis or care related to dialysis for a patient receiving end-stage renal disease hemodialysis,
- A patient admitted to the CCU because no other beds were available,
- A patient admitted to the ICU for close observation and monitoring of vitals (for example, due to a drug overdose), and
- A patient admitted to the ICU because hospital rules require certain treatments to be administered in a CCU.
What—and what not—to bill separately
Certain services are included in the critical care service and should not be reported separately when performed by a physician on the same day he or she bills for critical care. These include
- Interpretation of cardiac output measurements,
- Chest X-rays, professional component,
- Blood draw for specimen,
- Blood gases and information data stored in computers (for example, ECGs, blood pressure, hematologic data),
- Gastric intubation,
- Pulse oximetry,
- Temporary transcutaneous pacing, and
- Vascular access procedures.
No other procedure codes are bundled into the critical care services. Thus, other medically necessary procedure codes—such as CPR, endotracheal intubation, and placement of a central venous catheter—may be billed separately. To bill for these procedures, add modifier “–25” to the critical care code. This shows the critical care was separately identifiable and represented more than the normal pre- and post-service work associated with the procedure.
Billing for time
Since critical care codes are time-based, the duration of critical care services to be reported is the time the physician spent evaluating, treating and managing the critically ill or injured patient's care. That time may be spent at the immediate bedside or elsewhere on the floor or unit, as long as the physician is immediately available to the patient. Other services that may be counted toward critical care time include
- Reviewing test results,
- Discussing care with nursing staff or other physicians,
- Having telephone conversations with other physicians or staff on the floor while immediately available to the patient,
- Completing orders and other paperwork,
- Arranging transfer to another facility for emergent care,
- Discussing care (in person or by phone) with family members or other surrogate decision makers, if the patient is unable or incompetent to participate in giving a history and/or making treatment decisions, and the discussion is necessary for determining treatment decisions. All other family discussions, no matter how lengthy, may not be additionally counted toward critical care.
Time spent in activities that occur outside of the unit or off the floor (such as telephone calls taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care because the physician is not immediately available to the patient. This time is regarded as pre- and post-service work that is bundled into any E&M services.
What to document
Physicians should include all of the following when documenting for critical care services
The patient's condition. There must be proof that the patient is in system failure or that system failure is imminent. In addition, documentation must show that services were necessary to prevent further life-threatening deterioration of the patient's condition.
The complexity of the plan. Documentation must demonstrate that there was a need for highly complex decision making, which may include interpretation of multiple types of testing or application of advanced technologies. The plan must reflect an intensity of care that exceeds what is represented by other E&M codes.
Time spent providing services. This can be shown as the total number of minutes or by documenting the “time in” and “time out.” The in/out approach is the best way to demonstrate that critical care time is not overlapping when multiple physicians are involved in the case. Be careful to show that time involved in the performance of separately billable procedures was not counted toward critical care time. One may say, for example, “50 minutes of critical care, excluding time spent in procedures billed separately.”
The activities involved. These include review of tests and records, conversations with other physicians and staff, telephone calls (in the unit and available to the patient), preparing records, adjusting ventilators, writing orders, and talking with patients or family members.
Details of the family discussion. Include the following information
- The patient's status as unable or incompetent to participate in giving history and/or making treatment decisions;
- The necessity of having the discussion (for example, “No other source was available to obtain a history,” or “Because the patient was deteriorating so rapidly, I needed to immediately discuss treatment options with the family”);
- Medically necessary treatment decisions for which the discussion was needed; and
- A summary in the medical record that supports the medical necessity of the discussion.