CPT® Definition of Critical Care
Critical Care: It’s all about Condition, Time and Interventions!!

There are many at times, despite documenting the critical care minutes, the physicians are denied to get paid for his/her services. Do you know the reason why?

CPT® Definition of Critical Care

As per the CPT® definition “Critical illness or injury is an illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition”.

Critical care services are the medical services furnished by the physician directly to the critically ill patients. The critical medical care involves medical decision making of high complexity to evaluate, manipulate, and support vital organ system failure and/or to stall further life-threatening decline in patient’s health condition. Few vital organ failures to cite are a septic shock, acute respiratory failure, cardiac failure, hepatic failure, renal failure and/or multiple organ failures (MOF).

Centers for Medicare & Medicaid Services (CMS) additionally states that “the 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” in order to warrant for critical care for Medicare patients.

Key Areas of Focus:

The key areas that we may need to focus in regards to getting paid for critical care services are:

i) Time:   It is highly imperative that the duration of the medical service that was provided by the physician is documented.  This is the amount of time the physician spent to cater to the critically ill patient in terms evaluating, managing and providing care.

ii) Clinical Interventions: It is equally crucial to document the clinical intervention provided by the physician.

For example,

  • Patient diagnosed with Atrial Fibrillation, the intervention would more likely be the administration of an anticoagulant such as initiation of Heparin sodium drip.
  • Patient admitted for the Drug overdose, the possible intervention would be non-invasive positive pressure ventilation (BiPAP or CPAP);
  • Patient with acute respiratory failure, the possible intervention would be chest tube insertion etc.

For all of these conditions and interventions, the physician’s skill, keen observation, and personal attention are mandatory.

However, there are circumstances where the documentation lacks information either about the possible interventions or the total time of critical care provided. In both the scenarios, the coders should be cognizant of the potentiality of the chart going for critical care instead of billing as is. The medical coders should proactively query the physician for additional documentation that might qualify the service to be billed for critical care.

What makes the documentation clean for coding critical care service?

  1. Patient’s condition
  2. Clinical intervention
  3. Total time of care provided

Codes to be given:

99291Evaluation and management of the critically ill or critically injured patient;
first 30-74 minutes
99292Critical 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)
G0390Trauma response team associated with hospital critical care service

Code Right AND Get Paid!

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