Health Information Management

Learn documentation requirement for critical care coding in the ED

JustCoding News: Outpatient, June 27, 2012

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 by Lois E. Mazza, CPC

Emergency Departments (EDs) see a wide range of illnesses and injuries, from minor to major, which may require critical care. Coders need to understand how critical care is defined, what elements providers must document, and under what circumstances critical care can be coded for ED patients.

ED evaluation and management (E/M) codes, which coders assign by level, are based on documentation of history of present illness, exam, and medical decision making. Coders report critical care codes based on time, medical necessity, and interventions provided.

Critical care is defined as the direct delivery by a physician or provider of medical care to a critically ill or injured patient.

When defining critical illness or injury, consider the following:

  • One or more vital organs or organ systems are impaired
  • The patient’s condition has a high probability of immediate deterioration
  • If critical services are not immediately rendered, the patient faces a high probability of death

When providing critical care, the provider uses high complexity decision making to:

  • Assess, manipulate, and/or support vital organ function
  • Treat single or multiple vital organ failure
  • Prevent the further deterioration of the patient’s critical condition

Examples of vital organ failure include but are not limited to:

  • Central nervous system (such as stroke)
  • Circulatory system (such as heart attack)
  • Renal (such as acute renal failure)
  • Hepatic (liver failure)
  • Respiratory failure
  • Shock

When providing critical care, certain procedures are included and may not be separately billed. Those procedures include:

  • IV placement
  • Blood gas interpretation
  • Drawing of blood
  • Pulse oximetry interpretation
  • Ventilator management
  • Chest x-ray interpretation
  • Transcutaneous pacing

Other interventions may be billed separately, but coders must subtract the time used to perform the services from the total critical care time. These services include but are not limited to:

  • CPR
  • Intubation
  • Central line placement
  • EKG interpretations
  • Cardioversion
  • Tube thoracostomy
  • Laceration repair
  • Fracture care
  • Lumbar puncture

Defining time spent providing critical care

Critical care codes are time-based. The physician must document the total time spent providing critical care in the patient’s record. In order to charge for critical care services, the physician must document at least 30 minutes of critical care. If less than 30 minutes are provided, coders should report the appropriate E/M codes. For ED patients, coders would report E/M codes for emergency services.

Here are some quick guidelines for reporting critical care:

  • Physician must be in attendance at the bedside or immediately available in the unit or the immediate area of the patient during the time charged
  • Actual time spent providing care can be accumulated over a 24-hour period; however, only the time spent providing actual care may be charged
  • Physician must document total time spent providing critical care
  • Coders may not surmise that critical care was provided nor may they calculate actual time spent providing critical care based on diagnosis, interventions, or times written on physician notes
  • Codes are based on time: report CPT code 99291 for the first 30-74 minutes
  • Report CPT code 99292 for each additional 30 minutes

Along with time spent providing care at the bedside, the following activities may also be considered when determining time spent providing critical care:

  • Review of lab and other results
  • Consulting with other providers
  • Family meetings to ascertain medical care for patients unable to make their own decisions
  • Documentation of patient’s record

The provider must remain immediately available to the patient (in the immediate area of the patient’s bedside) while performing the above activities.

Coding challenges in the ED

Here are some common problem areas coders run into when reporting critical care services.

Patient is critical but does not spend 30 minutes in the ED. In many EDs, things move quickly. Trauma patients go to the operating room, patients with positive EKGs go to the cath lab and other urgent circumstances could make the stay in the ED short. Because of the time requirement for coding critical care, these cases cannot be coded using critical care codes. Level V ED E/M codes may be used if properly supported by documentation.

Critical care services clearly provided but no provider statement is found. As stated above, the physician must attest that critical care was provided and the amount of time he or she provided such care. Coders should look for a statement similar to this: I personally provided 30 minutes of critical care to this patient.

Some departments provided templates with a check box for such a statement and a blank where the physician can note the actual critical care time. These are fine as long as the physician actually checks the box and fills in the time.

As a coder, if you believe critical care has been provided but the necessary attestation is missing, you may be able to rectify the omission by:

  • Querying the physician: Some facilities have methods in place for coders to notify providers when their documentation needs to be completed or needs an addendum. Send a concise statement to the physician explaining what is needed and requesting the physician add the needed documentation to the record.
  • Physician education: Physicians are extremely busy. They may or may not be aware of documentation requirements. Some facilities have educators and/or auditors on site to provide physicians with information about needed documentation for optimal reimbursement. Some facilities allow coders to provide this information to physicians.
  • Escalate: When you encounter a record that you believe should be charged as critical care, but find no physician attestation, contact your manager for guidance. Some facilities have systems in place so that providers are notified if their documentation needs improving. Facilities often provide incentives for correct documentation. If you consistently see critical care cases that lack documentation, inquire about how you should make those in a position to further address it aware of the problem.

Critical care services are frequently provided in the ED setting. The following must be considered before coding:

  • Ppatient must be critically ill or injured and at risk for immediate deterioration or demise
  • Critical interventions should be provided
  • Time spent providing critical care must be attested to in the medical record by the provider

Coding for missed critical care services in the ED can significantly improve reimbursement. Careful review of the medical record along with physician education can increase the incidence of critical care coding in the ED.

Editor’s Note: Mazza is a documentation specialist for a medical management group that provides management services, as well as coding and billing services, for EDs, hospitalist medicine, and anesthesia groups in 46 states. She has 16 years experience working in the healthcare industry. Contact her at

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