Critical Care Coding

November 24th, 2014 / By Rebecca Caux-Harry

How many of us have worked for providers who, regardless of showing them the descriptor in the CPT book, insist upon charging critical care time for a patient in the ICU? For coders, the directions are clear: Regardless of the location of the patient, if the provider treated a critically ill or critically injured patient for 30 or more minutes, it is appropriate to report that service with a critical care code. So, when we see those magic words within the provider’s note, we submit the appropriate code(s). But, some coders don’t see the record. Some are just given a charge slip with the patient’s identifying information, procedure and diagnosis information. What is the right thing to do in this case? Because the critical care reimbursement is much higher than other E&M codes, some clinics review documentation for all critical care codes before submitting. Each group must decide how to handle the coding of these services.

How does the provider determine whether a specific patient qualifies for “critical” status? Not being a physician, I can guess at some obvious cases. I have watched medical dramas on television, after all! Patients presenting with a stroke or suffering critical injury due to an accident come quickly to mind. But, what about those patients that are a little less obvious, like a diabetic patient with sugars at 400? I once listened to a very interesting discussion between a group of Emergency physicians talking about patients in renal failure. They were debating certain lab values and how those results impact the risk of the patient and therefore the level of care for the service, and at some point, that service becoming critical care.

We coders are lucky. We aren’t the sick ones, and we aren’t the ones treating these very sick patients. We also aren’t the providers trying to make the determination between critically ill/injured and only severely ill/injured patients. We can educate providers about the requirements of documentation to support coding critical care when the provider has determined that the patient is critically ill or injured.

Selecting the correct critical care code is based on the age of the patient, status of the patient, initial verses subsequent visit and total time spent providing care (minus time spent performing non-bundled services). The time spent must be documented in the patient’s record, but doesn’t need to be solely face-to-face time. The provider should capture time spent engaged in care directly related to the individual patient. For pediatric patients in an inpatient setting, we have codes ranging from 99468-99476. Pediatric critical care is coded per day, rather than on time. CPT defines three groups within pediatrics for providing critical care services: neonates 0-28 days of age, pediatric 29 days through 24 months, and pediatric age 2 through 5 years of age. After age 5, we are directed to use the adult critical care codes which are based on time, codes 99291-99292. In the Emergency department or other outpatient setting, all critical care, regardless of patient age, is reported by time using 99291-99292.

The CPT manual contains a handy table with time ranges and how to select the appropriate code(s) based on time. For critical care time that doesn’t meet the minimum threshold of time to report critical care (30 minutes), report the appropriate E&M code based on the visit type. Multiple services are bundled into critical care time including cardiac output measures, pulse oximetry, interpretation of chest x-rays, blood gases and other data stored in computer systems, gastric intubation, temporary transcutaneous pacing, ventilator management and vascular access. Other services should be reported separately. The critical care clock stops when the provider performs services reported separately.

In some circumstances, a hospital or office visit can be coded on the same day as critical care, but this would not be a common occurrence. In a circumstance where a patient is seen by a provider, but later on the same day becomes critical, both services should be reported. This does not apply in the ED, however.

As described in previous blogs, documentation of these services is key. However, unlike regular E&M services, there aren’t specific documentation guidelines. The provider must give a clear picture of the status of the patient and an outline of the course of treatment during the critical care time, including all additional and included services performed.

Rebecca Caux-Harry, CPC, is the CodeRyte Product Specialist for Cardiology with 3M Health Information Systems.