Emergency medical professionals often face the challenge of accurately documenting and billing for critical care services. A seemingly straightforward case can become a billing error if the nuances of critical care time and diagnosis coding are not properly understood. Let’s delve into the crucial aspects of Critical Care Time Diagnosis Lists to ensure accurate medical billing and appropriate reimbursement for the life-saving care provided in emergency departments.
Understanding the CMS Definition of Critical Care
The Centers for Medicare & Medicaid Services (CMS) defines critical care as care provided to patients who are critically ill and require intensive monitoring and intervention. According to CMS, critical care is warranted when a patient’s medical condition meets two key criteria:
- Impairment of One or More Vital Organ Systems: The patient must exhibit dysfunction in at least one major organ system, such as cardiovascular, respiratory, renal, neurological, or metabolic systems. This impairment must be severe enough to pose a significant threat to the patient’s life.
- High Probability of Imminent or Life-Threatening Deterioration: Beyond current organ system impairment, there must be a substantial risk of the patient’s condition rapidly worsening or becoming life-threatening. This necessitates proactive and vigilant medical management.
Furthermore, critical care billing necessitates “frequent personal assessment and manipulation” of the patient’s condition by the physician. While conditions like cardiac arrest or severe trauma clearly fall under critical care, numerous other emergency department scenarios also qualify. The American College of Emergency Physicians (ACEP) provides valuable guidelines outlining conditions and interventions frequently associated with critical care billing, as detailed in Table 1.
Table 1: Conditions and Interventions Frequently Qualifying for Critical Care Billing
| CONDITIONS Frequently Qualifying for Critical Care Billing | INTERVENTIONS Often Associated with Critical Care Billing |
|---|---|
| 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 (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, except simple hypoglycemia) | Intravenous pacemaker insertion |
| Diabetic ketoacidosis or non-ketotic hyperosmolar syndrome | Invasive rewarming |
| Drug overdose | Non-invasive positive pressure ventilation (BiPAP or 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 requiring continuous monitoring (e.g., ACLS medications during cardiac arrest, insulin infusions, medications for heart rate/rhythm control, naloxone infusions, vasoactive medications) |
| Hyperkalemia | |
| Hyper- or hypothermia | |
| Hypertensive emergency | |
| Ischemia of limb, bowel, or retina | |
| Lactic acidosis | |
| Multiple trauma | |
| New onset paralysis | |
| Perforated abdominal viscus | |
| Pulmonary embolism | |
| Ruptured aneurysm | |
| Shock (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.
This table serves as a valuable reference for emergency physicians to identify conditions that frequently justify critical care billing and the associated interventions. Understanding this diagnosis list is the first step in accurate critical care time documentation.
Documenting Time Spent on Critical Patient Care
Unlike standard Evaluation and Management (E/M) coding, critical care billing is time-based. Accurate recording of time spent providing critical care is paramount. To bill for critical care time, a minimum of 30 minutes must be dedicated to direct and indirect patient care.
The Current Procedural Terminology (CPT) codes utilized for critical patient care are outlined in Table 2:
Table 2: Critical Patient Care CPT Codes
| CODE | SERVICE |
|---|---|
| 99291 | Reports the total critical care time for the first 30-74 minutes on a given date. Critical care time less than 30 minutes is billed using appropriate E/M codes. |
| 99292 | Used in conjunction with 99291 to report each additional 30 minutes of critical care beyond the initial 74 minutes. |
| G0390 | Added to 99291 for Trauma Team Activation when specific activation criteria are met at designated trauma centers. |
It’s crucial to understand that critical care time encompasses both direct and indirect patient care activities. This includes:
- Patient evaluation
- Communication with EMS personnel and family members
- Interpretation of diagnostic studies (labs, radiology)
- Consultations with specialists or admitting teams
- Data retrieval and chart review
- Documentation of the encounter
- Performance of procedures bundled into critical care
However, time spent performing separately billable procedures must be excluded from critical care time calculations. Table 3 differentiates between procedures typically bundled into critical care time and those billed separately.
Table 3: Bundled vs. Separately Billed Procedures in Critical Care
| Procedures BUNDLED into Critical Care Time Billing | Procedures Billed SEPARATELY |
|---|---|
| Interpretation of cardiac output, chest x-rays, pulse oximetry, blood gases, computer-stored data | 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 (in some contexts, verify local billing rules) |
| Wound repair | |
| ECG interpretation | |
| Electrical cardioversion |
While precise timing with a stopwatch is unnecessary, accurate tracking and documentation of total critical care time is essential. Key points to remember about critical care time are:
- Additive: Time spent throughout the patient encounter accumulates towards the total critical care time.
- Once per day: Critical care time can only be billed once per patient, per day, by a single physician.
- Non-continuous: Critical care time does not need to be continuous; it can be accumulated in segments.
- Attending Physician Involvement: Critical care time requires direct involvement and documentation by an attending physician. Resident physician time alone does not qualify for critical care billing.
Example Attending Physician Attestation for Critical Care Time
To ensure proper documentation, an attestation note from the attending physician is crucial. A template for such a note could include:
“I have discussed this case with the resident/mid-level provider. I personally performed a history and physical exam, and made independent medical decisions. I have reviewed the note and concur with the findings and plan, with the following exceptions: ____ (insert exceptions) ___.
Upon my evaluation, this patient presented with a high probability of imminent or life-threatening deterioration due to ___(condition)__, requiring my direct attention, intervention, and personal management.
I have personally provided ___ minutes of critical care time, excluding time spent on separately billable procedures. This time includes review of laboratory data, radiology results, discussions with consultants, and monitoring for potential decompensation. Interventions performed are as documented above.
– [Attending Physician Initials] [Time Stamp]”
This attestation clearly demonstrates the attending physician’s direct involvement and confirms the critical nature of the patient’s condition and the time spent providing critical care.
Key Elements for Documenting Critical Care Time
Adequate chart documentation is vital to justify critical care billing. The documentation must clearly articulate:
- Patient’s Critical Illness: Explicitly describe how the patient met CMS criteria for critical care, emphasizing organ system dysfunction and the high risk of deterioration.
- Interventions Provided: Detail all medical interventions performed for the patient, including medications, procedures, and monitoring.
- Cumulative Critical Care Time: State the total time spent on both direct and indirect critical patient care activities.
To strengthen documentation, consider including these specific points when applicable:
- Severity of illness and potential for decompensation.
- Vital sign abnormalities (hypotension, hypoxia, etc.) and their trends throughout the encounter.
- Diagnostic tests performed and your interpretation of the results.
- Treatments administered (supplemental oxygen, IV fluids, medications, blood transfusions, wound care, etc.).
- Procedures performed.
- Repeated assessments of patient status and response to interventions.
- Communication with EMS, patient, family, consultants, and admitting teams.
- Relevant information retrieved from chart review and its impact on patient care.
Remember that critical care documentation differs from standard E/M coding documentation. Critical care charts are not assigned an E/M level. However, if critical care criteria are not met, or if the time threshold of 30 minutes is not reached, the chart will be billed using E/M codes. In cases of uncertainty, documenting elements for both critical care and E/M coding is prudent.
Revisiting the STEMI Case: Critical Care Time in Practice
Consider the initial case of the STEMI patient rapidly transferred to the cardiac catheterization lab. While the patient clearly met the clinical criteria for critical care (organ system dysfunction and high risk), the emergency physician spent less than 30 minutes of cumulative critical care time. Consequently, the encounter was billed as a Level 3 E/M visit (code 99283).
This example highlights that even in high-acuity situations, if the documented critical care time falls short of 30 minutes, critical care billing is not justified. Therefore, in cases where the critical care time might be borderline, meticulous documentation of both critical care elements and E/M coding criteria is essential to ensure appropriate billing.
Strategies for Efficient and Accurate Critical Care Documentation
- Recognize Critical Care Opportunities: Be mindful of the CMS criteria and the diagnosis list for critical care. Emergency physicians frequently provide critical care without realizing they are meeting billing requirements. Reflect on your practice to identify potential missed critical care billing opportunities.
- Prioritize Medical Decision Making Documentation: Critical care charting prioritizes documenting the patient’s critical illness, interventions, and time spent. Detailed history and physical exam elements required for E/M coding are less critical in properly documenting critical care. Focus your documentation efforts on medical decision-making aspects.
- Utilize Macros and Templates: Employing pre-built macros or templates can significantly streamline critical care documentation, ensuring all necessary elements are captured efficiently and consistently.
By mastering the critical care time diagnosis list, understanding CMS guidelines, and implementing effective documentation strategies, emergency medical professionals can ensure accurate billing for the vital critical care services they provide.
Additional Resources:
ED Charting and Coding Series
Alt Text: Kenneth Dodd MD, Emergency Medicine-Internal Medicine Chief Resident Critical Care Fellow, Hennepin County Medical Center
Kenneth Dodd, MD
Emergency Medicine-Internal Medicine Chief Resident Critical Care Fellow Hennepin County Medical Center
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Alt Text: Ted Fan MD, Emergency Medicine Chief Resident, Department of Emergency Medicine, George Washington University
Ted Fan, MD
Emergency Medicine Chief Resident Department of Emergency Medicine George Washington University
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