Emergency departments are fast-paced environments where critical decisions are made rapidly. Consider a scenario: paramedics rush a patient into the emergency department (ED) following a STEMI activation. The cardiac catheterization team swiftly takes over, and within minutes, the patient is whisked away. “Textbook resuscitation,” you might think, satisfied with a job well done and the seamless transition. You meticulously document 20 minutes of critical care, only to later find the chart flagged for incorrect critical care time, downgraded to a Level 3 visit (E/M code #99283). What went wrong? Understanding the nuances of critical care billing, particularly the Critical Care Diagnosis List, is crucial for accurate medical coding and appropriate reimbursement.
Understanding the CMS Definition for Critical Care Billing
The Centers for Medicare & Medicaid Services (CMS) defines critical care as care provided to patients with illnesses or injuries that “impair one or more vital organ systems” and for whom “there is a high probability of imminent or life-threatening deterioration in the patient’s condition.” Furthermore, critical care necessitates “frequent personal assessment and manipulation” of the patient’s condition by the physician. While conditions like cardiac arrest, major trauma, and ICU-level illnesses clearly qualify, many emergency medicine scenarios also meet these criteria. Emergency physicians regularly manage conditions and perform interventions that justify critical care billing, provided they align with the critical care diagnosis list and documentation guidelines.
Table 1: Critical Care Diagnosis List and Associated Interventions
| CONDITIONS Frequently Qualifying for Critical Care | INTERVENTIONS Often Associated with Critical Care |
|---|---|
| Acute Coronary Syndrome with Active Chest Pain | Arterial Line Placement |
| Acute Hepatic Failure | Major Burn Care |
| Acute Renal Failure | Cardiopulmonary Resuscitation (CPR) |
| Acute Respiratory Failure | Chest Tube Insertion |
| Adrenal Crisis | Cricothyrotomy |
| Aortic Dissection | Defibrillation/ Cardioversion |
| Bleeding Diatheses (e.g., Aplastic Anemia, DIC, Hemophilia, ITP, Leukemia, TTP) | Delivery of Baby |
| Burns Threatening to Life or Limb | Emergent Blood Transfusions |
| Cardiac Dysrhythmia Requiring Emergent Treatment | Endotracheal Intubation |
| Cardiac Tamponade | Major Hemorrhage Control |
| Coma (Most Etiologies, Excluding Simple Hypoglycemic) | Intravenous Pacemaker Insertion |
| Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycemic State (HHS) | Invasive Rewarming |
| Drug Overdose | Non-Invasive Positive Pressure Ventilation (NPPV) (e.g., BiPAP, CPAP) |
| Ectopic Pregnancy with Hemorrhage | Pericardiocentesis |
| Embolus of Fat or Amniotic Fluid | Therapeutic Hypothermia |
| Envenomation | Trauma Care Requiring Multiple Surgical Interventions or Consultants |
| Gastrointestinal Bleeding | Ventilator Management |
| Head Injury with Loss of Consciousness | Parenteral Medications Necessitating Continuous Monitoring, such as: – ACLS Medications During Cardiac Arrest – Insulin Infusions – Medications for Heart Rate/Rhythm Control – Naloxone Infusions – Vasoactive Medications |
| Hyperkalemia | |
| Hyperthermia or Hypothermia | |
| Hypertensive Emergency | |
| Ischemia of Limb, Bowel, or Retina | |
| Lactic Acidosis | |
| Multiple Trauma | |
| New Onset Paralysis | |
| Perforated Abdominal Viscus | |
| Pulmonary Embolism (PE) | |
| Ruptured Aneurysm | |
| Shock (All Etiologies: Septic, Cardiogenic, Spinal, Hypovolemic, Anaphylactic) | |
| Stroke (Hemorrhagic or Ischemic) | |
| Status Epilepticus | |
| Tension Pneumothorax | |
| Thyroid Storm |
© 2011-2016, American College of Emergency Physicians. Reprinted and modified with permission.
Image alt text: Table showcasing a critical care diagnosis list with associated interventions, crucial for understanding medical billing in emergency medicine.
This critical care diagnosis list (Table 1) serves as a guide, highlighting conditions that often meet the criteria for critical care billing. It’s important to note that this is not exhaustive, and clinical judgment remains paramount. The presence of a condition on this list does not automatically qualify for critical care billing; the severity of the patient’s condition and the intensity of intervention are equally important.
Time is of the Essence in Critical Patient Care and Billing
Critical care billing is distinct from standard Evaluation and Management (E/M) coding in its emphasis on time. The time spent providing critical care must be meticulously documented and is billed using specific Current Procedural Terminology (CPT) codes. Unlike E/M codes, which can be based on the complexity of medical decision-making or time, critical care billing has a minimum time threshold. Emergency physicians must dedicate at least 30 minutes of critical care time to a patient on a given date to bill for critical care services. Time spent under 30 minutes defaults to standard E/M coding.
Table 2: Critical Care CPT Codes
| CODE | SERVICE Description |
|---|---|
| 99291 | Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes |
| 99292 | Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) |
| G0390 | Trauma activation; includes team activation and physician attendance |
Table 3: Bundled vs. Separately Billed Procedures in Critical Care
| Procedures BUNDLED into Critical Care Time Billing | Procedures Billed SEPARATELY from Critical Care Time |
|---|---|
| Interpretation of: – Cardiac Output – Chest X-rays – Pulse Oximetry – Blood Gases – Data Stored in Computers | Endotracheal Intubation |
| Gastric Intubation (e.g., Nasogastric Tubes) | Central Vascular Access |
| Temporary Transcutaneous Pacing | Intraosseous Line Placement |
| Ventilatory Management | Transvenous Pacing |
| Blood Draws for Specimen | Chest Tubes |
| Peripheral Vascular Access | CPR |
| Wound Repair | |
| ECG Interpretation | |
| Electrical Cardioversion |
Image alt text: Critical care billing procedures table distinguishing bundled and separately billed services, essential for accurate medical coding.
Both direct and indirect patient care activities contribute to critical care time. This includes time spent on:
- Patient assessment and examination
- Communication with EMS personnel and family members
- Interpretation of diagnostic studies (labs, imaging)
- Discussions with consultants and admitting teams
- Data retrieval and chart review
- Documentation of the encounter
- Performance of procedures bundled into critical care (Table 3)
Crucially, time spent on separately billable procedures (Table 3) cannot be included in critical care time calculations. While precise timing isn’t necessary for each task, accurate tracking and documentation of total critical care time are essential for proper billing. Key points to remember about critical care time:
- Additive: Cumulative time spent throughout the encounter counts.
- Once per day: Billable only once per patient, per day, by a single physician group.
- Non-continuous: Time intervals do not need to be consecutive.
- Attending physician involvement: Requires direct involvement and documentation by an attending physician; resident time alone is not reimbursable under the attending’s billing.
Essential Elements of Critical Care Time Documentation
Adequate documentation is paramount to justify critical care billing and ensure compliance. Your chart should clearly articulate:
- The patient’s critical illness: Detail how the patient met CMS criteria, referencing the critical care diagnosis list if applicable and explaining the organ system dysfunction and high risk of deterioration.
- Interventions provided: Document all actions taken to manage the patient’s critical condition.
- Cumulative critical care time: Explicitly state the total time spent on critical care, encompassing both direct and indirect care activities.
To strengthen your documentation, consider including these points:
- Severity of illness and decompensation risk: Highlight the acuity and instability of the patient’s condition.
- Vital sign trends: Document abnormal vital signs (hypotension, hypoxia, tachycardia, etc.) and their changes in response to treatment.
- Diagnostic test interpretation: Record tests performed, your interpretation of results, and how they influenced management.
- Treatments administered: Detail specific therapies, such as oxygen supplementation, intravenous fluids, medications, blood transfusions, and wound care.
- Procedures performed: List all procedures, differentiating between bundled and separately billable ones.
- Re-assessments and response to interventions: Document ongoing evaluations and the patient’s response to treatments.
- Communication details: Note conversations with EMS, patient, family, consultants, and admitting teams, and their impact on care decisions.
- Chart review insights: Explain relevant information gleaned from chart review and its influence on patient management.
Remember, critical care documentation diverges from standard E/M coding guidelines. Critical care charts are not assigned an E/M level, as these coding systems are mutually exclusive. However, if critical care criteria are not met (either in diagnosis or time), the encounter will be billed according to E/M codes. Therefore, in cases where critical care billing is uncertain, documenting elements supporting E/M coding levels is prudent.
Revisiting the STEMI Case: Time is Critical
Returning to our STEMI patient scenario: while the patient undoubtedly met the CMS criteria for organ system dysfunction and high risk (a critical care diagnosis list condition), the provider’s documented critical care time was less than 30 minutes. Rapid stabilization and transfer to the cath lab, while excellent patient care, resulted in insufficient critical care time for billing purposes. Consequently, the chart was appropriately coded as a Level 3 E/M visit (99283). If there’s a possibility of falling short of the 30-minute critical care threshold, ensure your documentation also supports E/M coding criteria.
Working Efficiently for Accurate Critical Care Billing
Emergency physicians frequently provide critical care without recognizing its billable potential. Reflect on your practice and identify opportunities to capture critical care billing when appropriate. Leverage the documentation flexibility of critical care coding: a critical care chart doesn’t require the detailed history and physical exam elements of E/M level billing. Focus your documentation on medical decision-making, clearly articulating the patient’s critical illness, your interventions, and the total critical care time. Utilizing macros or templates within your Electronic Health Record (EHR) can streamline critical care documentation, ensuring efficiency without sacrificing thoroughness and accuracy. By understanding the critical care diagnosis list, time requirements, and documentation guidelines, you can ensure accurate billing and appropriate reimbursement for the critical care services you provide.
Additional Resources
ED Charting and Coding Series
Kenneth Dodd, MD
Emergency Medicine-Internal Medicine Chief Resident Critical Care Fellow Hennepin County Medical Center
Ted Fan, MD
Emergency Medicine Chief Resident Department of Emergency Medicine George Washington University
