November 5, 2024

Medical Coding Critical Care

By Janine Mothershed
Guidelines for Coding and Billing Critical Care: An Overview for Coders and Billers

Critical care services are crucial in treating patients with life-threatening conditions. Accurate coding and billing for these services are essential to ensure proper reimbursement and compliance with healthcare regulations. Critical care involves the provision of intensive monitoring and treatment for patients who require constant attention due to severe or complicated medical conditions. This blog outlines the key guidelines for coding and billing critical care services in accordance with the Current Procedural Terminology (CPT) and ICD-10-CM codes.

What is Critical Care?

Critical care is defined as the direct delivery of medical care by a physician to a critically ill or injured patient. The patient must be in a state where life-sustaining interventions are required to prevent imminent death, irreversible organ system failure, or other conditions that may lead to prolonged or permanent disability.

Examples of critical care conditions include:

  • Cardiac arrest
  • Respiratory failure
  • Sepsis
  • Stroke
  • Major trauma

Critical care services are provided in various settings, such as emergency departments, intensive care units (ICUs), and other specialized care units.

Critical care services include but are not limited to, the treatment or prevention of further deterioration of central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, or overwhelming infection.

The provider’s service must be medically necessary and meet the definition of critical care services as described below in order to be considered covered.

  • Critical Care Definition– Critical care is the direct delivery by a physician(s) of medical care for a critically ill or injured patient.
    • The care of such patients involves decision-making of high complexity to assess, manipulate, and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple vital organ system failure or to prevent further deterioration.
    • It may require extensive interpretation of multiple databases and the application of advanced technology to manage the patient.
    • Critical care services include but are not limited to, the treatment or prevention or further deterioration of central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, postoperative complications, or overwhelming infection.

In order to reliably and consistently determine that delivery of critical care services rather than other evaluation and management (E/M) services is medically necessary, both of the following medical review criteria must be met in addition to the Current Procedural Terminology (CPT) Manual definitions:

  • Clinical condition criterion – There is a high probability of sudden, clinically significant, or life-threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently.
  • Treatment criterion – Critical care services require direct personal management by the physician. They are life and organ-supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration in the patient’s condition.

Providing medical care to a critically ill patient should not be automatically classified as a critical care service for the sole reason that the patient is critically ill.

For any given period of time spent providing critical care services, the provider must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

Time involved in performing procedures that are not bundled into critical care (i.e., billed separately) may not be included and counted toward critical care time.

The provider’s progress note must document that time involved in the performance of separately billable procedures was not counted toward critical care time.

Time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options may be counted toward critical care time only when:

  • The patient is unable or incompetent to participate in giving a history and/or making treatment decisions,
  • The discussion is absolutely necessary for treatment decisions under consideration that day, and
  • All of the following are documented in the provider’s progress note for that day:
    • The patient was unable or incompetent to participate in giving history and/or making treatment decisions, as appropriate,
    • The necessity of the discussion (e.g., no other source was available to obtain a history” or “because the patient was deteriorating so rapidly needed to discuss treatment options with family immediately”),
    • The treatment decisions for which the discussion was needed, and
    • The substance of the discussion is related to the treatment decision.
  • The physician’s progress note must link the family discussion to a specific treatment issue and explain why the discussion was necessary on that day.
  • All other family discussions, no matter how lengthy, may not be counted towards critical care time.

Services must be medically necessary and meet the requirements of critical care services. Care provided to patients who do not meet all of the criteria for critical care are reported using the appropriate E/M code depending on the level of service provided.

CPT Codes for Critical Care Services

The CPT coding system includes specific codes to report critical care services. The following are key codes used to describe critical care:

CPT Code 99291 – Critical Care, First Hour

This code is used to report the first 30 to 74 minutes of critical care given on the same date. This code can be used ONLY ONCE per calendar date. Time spent DOES NOT need to be continuous. The time MUST be documented in the chart. The physician must spend over 30 minutes in total critical care time on any ONE calendar date to use the 99291. Time spent of less than 30 minutes (even if the care is critical) is reported using the normal hospital E/M codes. This includes:

  • Continuous monitoring of vital signs and organ systems
  • Direct bedside care
  • Administration of medications, fluids, or other interventions
  • Interpretation of diagnostic data

The code requires that the physician or other qualified healthcare provider is physically present at the bedside and providing continuous attention to the patient.

CPT Code 99292 – Critical Care, Each Additional 30 Minutes

This code is used to report EACH additional 30-minute block of time beyond the first hour of critical care on any given calendar date. This code is used ONLY in conjunction with the 99291 code. EACH additional thirty minutes beyond the first hour of critical care is reported using this code.

Examples:

If you spend 90 minutes on critical care on one calendar date, the encounter would be reported by using the 99291 for the first hour, plus one 99292 code used to report the additional 30 minutes. Please be aware that the 99292 has a 15-minute threshold which must be crossed before each 30-minute increment can be billed.

If you provided 74 minutes of critical care on ONE calendar date, this encounter would be reported using ONLY the first hour 99291 code (because the 15-minute threshold for the additional 30-minute code was not crossed). On the other hand, if you spent a total of 75 minutes during that ONE calendar date on critical care, you would report both the 99291 (for the first 60 minutes) and the 99292 for the additional 15 minutes. This encounter would be reported by using both codes.

CPT Code 99223 – Critical Care Services (Hospital Inpatient)

This code is used for critical care services rendered to hospital inpatients, including the initial evaluation and management of critically ill patients. It is typically reported in addition to 99291 and 99292 for the inpatient setting.

Time-Based Billing for Critical Care

Critical care services are time-based, meaning the number of minutes spent providing care directly influences billing. The clock starts when the physician or healthcare provider begins delivering critical care services and ends when those services are no longer required.

  • First hour: 99291 (includes the first 30 minutes of critical care services)
  • Each additional 30 minutes: 99292 (for each additional half-hour beyond the first hour)

Important Note: Critical care time is counted only for time spent directly delivering care to the patient. Indirect services (e.g., reviewing test results or writing notes) are not included in the critical care time calculation.

Documentation Guidelines

Proper documentation is crucial for accurate coding and billing of critical care services. The following points should be documented:

  • Patient condition: The patient’s critical state should be clearly documented, including the specific medical conditions being treated.
  • Time spent: Document the exact amount of time spent providing critical care. This time must be continuous and can be cumulative over a 24-hour period.
  • Interventions performed: Include a detailed description of the procedures, treatments, and assessments made by the physician or healthcare provider during the critical care episode.
  • The severity of the condition: Document the severity of the patient’s condition and how it justifies the need for critical care services.

Key Considerations for Billing Critical Care

Simultaneous Critical Care

If more than one provider delivers critical care to a single patient during the same time period, only one provider can bill for the service. However, both providers can document their time separately if they perform different aspects of care or services during the same critical care event.

Non-Critical Care Services

It is important to distinguish between critical care services and other types of care. For instance, non-critical procedures like routine imaging or diagnostic tests, while important, do not qualify as critical care and should be reported using other appropriate codes.

Critical Care and Other Services

Critical care can often overlap with other services, such as surgical procedures, anesthesia, or emergency room services. However, in such cases, critical care services should be separately documented and billed, and providers should use the appropriate codes to avoid double billing.

Time Spent in Observation Status

Time spent in the observation unit (rather than an ICU or emergency department) may not qualify for critical care coding unless the patient is critically ill. Observation services typically fall under CPT codes 99218-99220 or 99224-99226.

Telehealth and Critical Care

As telehealth becomes increasingly common, it’s important to note that telehealth visits for critical care can be billed, but the services provided must meet the same standards as in-person care. Telehealth services often require a different set of modifiers (e.g., modifier 95 or G2025), and specific requirements must be met to ensure that the care delivered qualifies as critical.

Billing and Reimbursement

Reimbursement for critical care services is typically based on the time spent providing direct care and the complexity of the patient’s condition. The following factors should be considered:

  • Insurance guidelines: Different insurance companies may have different criteria for critical care services. Always verify the insurer’s policies for specific billing and documentation requirements.
  • Coding compliance: Accurate coding is essential to avoid claims denials or audits. Ensure that critical care services are billed according to the CPT and ICD-10 guidelines.
  • Modifiers: Use appropriate modifiers when applicable (e.g., modifier 25 for a separate and distinct service).

Critical care services are vital for the management of severely ill patients and require meticulous documentation and accurate coding to ensure proper reimbursement and compliance. Providers must ensure that the services they provide meet the criteria for critical care as defined by the CPT and ICD-10 coding systems. Properly documenting the patient’s condition, interventions, and time spent in critical care is essential for maximizing reimbursement and minimizing the risk of audits. By following these guidelines, healthcare providers can help ensure that they are compensated appropriately for the critical care services they deliver.

Key Takeaways:

  • Critical care codes are time-based, and accurate documentation of time spent is critical.
  • Only one provider can bill for simultaneous critical care services, even if multiple providers are involved.
  • Distinguish critical care from other types of care to avoid billing errors.
  • Insurance policies may vary, so always verify requirements before billing.

By adhering to these guidelines, healthcare providers can navigate the complex landscape of critical care billing and ensure proper reimbursement while maintaining compliance with industry standards.

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