Health Information Management

Q/A: Level 5 ED visit or critical care?

APCs Insider, June 4, 2010

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Q: When does a level 5 ED visit become a critical care visit? Many providers have asked me this question. Many level 5 patients also could meet the criteria for a critical care visit (e.g., myocardial infarctions or CVAs). Is there a method for determining whether level 5 or critical care is appropriate?

A: Reporting critical care services is not dependent solely on a specific diagnosis or situation. Providers must meet intensity of service and face-to-face time requirements to report critical care services. CPT introductory guidelines, beginning on page 20, define critical care:

“Critical care is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury 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. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.”

The CPT definition of code 99291 (critical care) specifically states “30–74 minutes”. Therefore, the record must include specific documentation that supports this time frame to report this code.

CPT Assistant, July 2006, states:

Is it appropriate to report the critical care services codes if the total duration of critical care time is less than 30 minutes?

Critical care services are reported using code 99291 for the first 30 to 74 minutes. If the total duration of critical care services is less than 30 minutes on a given date of service, then the appropriate E/M code should be reported.

If either the time requirement or level of care defined by CPT are not clearly documented in the medical record, Critical Care Services (CPT 99291, 99292) cannot be reported. The ED level reported will then depend on the hospital’s internal E/M criteria established to reflect their individual Emergency Department resources. It is crucial that the documentation support the resources utilized and thus the level of service reported.

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