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Male Patient Talking To Medical Staff In Emergency RoomToday, more than ever, medical coders are a difficult resource to identify, recruit and retain. When an organization considers the total costs of hiring a coder which includes recruitment costs, salary, benefits, office space, coding software and related you are left with a per resource annual cost that can be quite high. In addition to staffing concerns, revenue cycle leaders must contend with the complexity and challenges that are being created through the spread of myriad software systems.


Edelberg & Associates help hospitalists accurately document the Evaluation & Management(E/M) services they provide patients. Many hospitalists do more for a patient than what is reflected in documentation. With our certified medical coders who specialize in hospitalist medicine, we can help inform hospitalists about proper coding and review their documentation. Using our coding and analytic software solution, providing feedback and education to the hospitalist is key.

Documentation Guidelines for Billing Critical Care

Documentation and billing for the hospital component of critical care continue to present a challenge for hospitals as the rules, based somewhat on CPT but with a twist added by the Centers for Medicare & Medicaid Services (CMS), differ enough from the professional rules to create a significant challenge.

When critical care services are provided, the hospital may bill CPT code 99291, Critical Care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. If additional Critical Care time is documented over 74 minutes, 99292 Critical Care would be billed for each additional 30 minutes of critical care (or part thereof). Time, intensity and content of the service form the foundation of this Evaluation and Management service.

Critical care is defined as a critical 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. Key to understanding appropriate billing of critical care is an understanding of how a routine Evaluation and Management service makes the jump to critical care. As the CPT guidelines indicate, hospitals that provide less than 30 minutes of critical care should bill for a visit, typically an evaluation and management visit, at a level consistent with their own internal guidelines.

Critical care requires decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition. Examples of vital organ system failure include, but are not limited to central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.

The time spent managing the critical patient is the key factor. For the hospital to bill this service, documentation must support a minimum of 30 minutes of critical care service to the patient. Medicare PUB 100-94 MCP, Transmittal 1139, Dec 22, 2006 stated this 30 minute minimum has always applied under the OPPS and will continue to apply . . . CMS says that under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or injured patient.

If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once. Thus, to assure you can code this service correctly, documentation must clearly state the start and stop times spent with the patient by each health care provider so that coding professionals can accurately count individual and group provider times accurately.

Critical care includes certain other separately identifiable procedures or services that are included in the critical care package and cannot be billed separately. These include interpretation of cardiac output measurements, chest X-rays, pulse oximetry, blood gasses, information data stored in computers, gastric intubation, temporary transcutaenous pacing, ventilatory management and vascular access procedures. (CPT provides the codes related to each of these bundled services.) Additional procedures provided during the visit are paid separately.

Critical patients often require life-saving interventions. One of the most frequent is CPR. When cardiopulmonary resuscitation is performed without other evaluation and management services, e.g., a physician responds to a code blue, directs CPR, then the patient’s attending physician resumes care of the patient), only the CPT code 92950 for CPR should be reported. The levels of critical care are determined by time so when CPT code 92950 is reported, the time required to perform CPR is not included in critical care. Additional procedures provided by HM staff or consultants supported by HM staff are separately billable by the hospital as long as the time spent performing these procedures is removed from the time used to determine critical care.

The following services are included in "critical care" time when performed during the critical period by the same physician(s) providing critical care and should not be reported separately:

  • the interpretation of cardiac output measurements (CPT 93561, 93562)
  • pulse oximetry (CPT 94760, 94761, 94762)
  • chest x-rays, professional component (CPT 71010, 71015, 71020)
  • blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data-CPT 99090)
  • gastric intubation (CPT 43752, 43753)
  • transcutaneous pacing (CPT 92953)
  • ventilator management (CPT 94002-94004, 94660, 94662)
  • peripheral vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600)

Any services performed that are not listed above may be reported separately.

Examples of common procedures that may be reported separately for a critically ill or injured patient include (but not limited to):

  • CPR (92950) (while being performed)
  • Endotracheal intubation (31500)
  • Central line placement (36555, 36556)
  • Intraosseous placement (36680)
  • Tube thoracostomy (32551)
  • Temporary transvenous pacemaker (33210)
  • Electrocardiogram- routine ECG with at least 12 leads; interpretation and report only (93010)
  • Elective electrical cardioversion (92960)

This list is not exhaustive but merely provides examples of separately billable procedures that may be reported in addition to critical care.

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