Health Information Management

Understanding and coding for critical care services

JustCoding News: Inpatient, January 6, 2010

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by Lois E. Mazza, CPC, PCA

Critical care is the direct delivery of medical care, by a physician(s), for a critically ill or critically injured patient. CMS defines critically ill and injured patients as those who are experiencing one or more vital organ failure(s) and who have a high probability of life threatening deterioration in their condition.

Some examples of vital organ failure include:

  • Central nervous system (i.e., brain, spinal cord).
  • Shock
  • Circulatory failure (i.e., heart, blood vessels)
  • Renal failure (i.e., kidneys)
  • Hepatic failure (i.e., liver)
  • Metabolic failure
  • Respiratory failure (i.e., lungs)

Other life threatening conditions could also contribute to the patient’s critical condition.

Physicians often use the latest technologies to treat critical care patients; however, physicians can also render critical care in situations in which they do not employ these technologies.

For critical care situations, the medical decision-making, assessments, and other care the physician provides is typically of high complexity. To charge for critical care, the patient must have a critical diagnosis or critical symptoms. Click here for a listing of some common critical diagnosis and symptoms.

Critical care settings

Large medical facilities usually have intensive care units (ICU), where critical patients receive care. Some facilities have multiple units depending on the circumstances and needs of the community. ICUs might be located near the operating rooms for critical postoperative patients, or near the telemetry floor for patients who have life threatening cardiac issues (e.g., cardiac care units).

Some hospitals have ‘step down’ units for patients who are well enough to vacate the ICU but still require a more intensive level of care than what would be available on a regular nursing unit.

Typically, only critical care patients are in the ICU. However, when a patient is in the ICU as a ‘boarder,’ due to a lack of available space in the facility, and this patient does not have a critical diagnosis or critical symptoms, then coders should report other appropriate evaluation and management (E/M) codes.

Physicians also often administer critical care in other areas of the facility, such as the ED or the nursing floor when a patient experiences a life-threatening medical event (e.g., cardiac arrest, stroke).

Services included in critical care codes

The following services are included in critical care codes, so coders should not report them separately:

  • The interpretation of cardiac output measurements
  • The interpretation of chest x-rays
  • Noninvasive ear or pulse oximetry for oxygen saturation 
  • Analysis of clinical data, stored in computers (e.g., electrocardiograms, blood pressures, hematolgic data)
  • Gastric intubations, requiring a physician’s skill as well as fluoroscopy, image documentation and report
  • Temporary transcutaneous pacing (i.e., a temporary method of keeping the patients heart beating by delivering small jolts of electricity to the heart)
  • Ventilatory management for patients who have been placed on ventilators to assist with breathing
  • Vascular access procedures for the purpose of drawing blood samples

Coders may separately report for services not listed above that the physician performs to care for critically ill and critically injured patients.

Although the physician rendering critical services cannot separately report the services above, when the providing physician requires the expertise of another physician to render these services, then the second provider may charge for them.

For example, the physician who is providing critical care may decide a gastric intubation is necessary, but finds that because of the patient’s body habitus, he or she is unable to do so. The critical care provider might request the assistance of a colon-rectal surgeon to perform the gastric intubation. The colon-rectal surgeon may then charge a fee for these services.

Time-based codes

Report critical care based on the time spent providing care. There are two codes used for critical care:

  • CPT code 99291: Critical care, evaluation and management of the critically ill or critically injured patient; first 30–74 minutes.
  • CPT code +99292: Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes. (List separately in addition to primary service.)

Report code +99292 more than one time if the physician spends more than 30 additional minutes. For example, consider the following:

  • For 75–104 minutes: Use 99291 X 1 and 99292 X 1
  • For 105–134 minutes: Use 99291 X 1 and 99292 X 2
  • For 135–164 minutes: Use 99291 X 1 and 99292 X 3
  • For 165–194 minutes: Use 99291 X 1 and 99292 X 4

The critical care codes coders assign should reflect the total time spent for each 24-hour period the physician provided critical care. The time does not have to be continuous.

The critical care attending should clearly document in the patient record each time he or she provided care for the critical patient within each 24-hour period, including the total amount of time spent with the patient, at his or her bedside providing care or in the unit or nursing floor.

The physician may charge for time spent:

  • Reviewing test results
  • Discussing the patient's care with staff members
  • Documenting critical services in the patient's record 

The physician must remain immediately available while carrying out these tasks.

When the physician spends fewer than 30 minutes providing critical care, use the appropriate E/M codes.

CPT Manual guidelines state, “Critical care and other E/M services may be provided to the same patient on the same day by the same physician,” meaning that it is appropriate for a physician to charge critical care services and separate E/M services on the same day.

For example, a physician admits a patient for a non-life threatening ailment or procedure. The physician sees the patient in the morning and reports an E/M charge. That afternoon, the patient suffers a cardiac arrest and goes into respiratory failure. This requires critical care from the physician, who can then report a critical care charge for those services he or she provided on that same day.

In summary, to charge critical care codes:

  • The patient must be have a critical diagnosis or symptom
  • There must be a critical diagnosis or symptom(s), regardless of the area where the physician provides services
  • Care provided must require complex medical decision-making by the physician
  • The physician must clearly document in the medical record the time spent providing critical care

Editor’s note: Lois E. Mazza, CPC, PCA, is a certified professional coder at Lahey Clinic Medical Center in Burlington, MA. E-mail her at Lois.E.Mazza@lahey.org.



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