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Critical Care in 2017

Some Thoughts to Improve Documentation and Assure Correct Coding

Determining what constitutes critical continues to stump physicians and coding professionals into 2017.  As a result, determining Critical Care for professional and technical services still remains a subjective area of E/M coding.  Although CMS has attempted to clarify the content and determining factors for critical care services, it seems no two coders or providers can agree on which patients qualify for this service when patients are not “obviously” critical.  If we look at the most recently calculated Medicare E/M distribution for the nation as posted on the ACEP website (ACEP.org) we see where Critical Care typically falls out in terms of its utilization compared to other E/M levels:

table1

And yet a quick review of how it is billed in individual Continental United States from lowest Critical Care to highest:

table2

That’s a pretty significant difference and could be attributed to several factors:

  • Maine may have a healthier or younger population
  • Nevada may have a high elderly/retired population
  • Nevada may have a high tourist population so the statistics may not be unique to Nevada residents;
  • Coding policies might be more conservative in Maine thus fewer visits are actually coded as critical care
  • Documentation could be less detailed in Maine thus fewer visits actually qualify for coding at the Critical Care level even though the patient’s condition may actually meet the Critical Care criteria;
  • Nevada’s coding and physician documentation training could be more aggressive – particularly at the higher acuity levels

And so on . . . .!

So, as we begin to dissect the components of Critical Care, let’s begin with what we know based on the CPT and CMS literature.
Critical Care Codes:

  • 99291 – Critical care, evaluation and management of the critically ill or critically ill patient; first 30-74 minutes
  • 99292 – Critical care, evaluation and management of the critically ill or injured patient; each additional 30 minutes

Critical Care code 99291 may be coded only one time per day by the same provider or group, even if the time spent by the provider is not continuous on that date. Code 99292 is used to report additional blocks of time.  The key here is that the provider(s) must remember to document the time spent performing critical care.  As we will discuss below, there is a distinct difference in how critical care is defined between professional and technical coding.

Critical Care is the evaluation and management of a critically ill or injured patient, requiring the constant, but not always continuous, attendance of the provider. Critical Care does not require documentation of a specific number of elements of history (History of Present Illness, Review of Systems and Past, Family, Social History) or specific elements the physical examination, but it does require:

  1. High complexity decision-making (including assessment, manipulation and support of vital system functions)
  2. Documentation of at least 30 minutes of constant attention by the provider

According to CPT, “Critical Care is the direct delivery by a physician(s) or other qualified health professional of medical care for a critically ill or injured patient.” To our knowledge, neither Medicare nor Medicaid nor any other payer has listed every possible Critical Care scenario or even a significant example of what really constitutes critical care. However, CPT does define the following similar characteristics:

  • “A critical illness or injury 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 involves high complexity decision-making to assess, manipulate, and support vital system function(s) to treat single or multiple 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.”
  • “Although Critical Care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life-threatening situations when these elements are not present.”

So let’s break down what we know.  The critical illness or injury with a “high probability of imminent or life threatening deterioration in the patient’s condition” could, and often does, vary between the ED and an inpatient hospital stay.  Often the emergency physician is performing the extensive workup to determine whether or not a high probability exists.  Until the workup is performed, the emergency physician has only the history with risk factors, the chief complaint and presenting problem and the general observation of the patient’s condition which must be clearly documented in order to support the need for additional testing and the final disposition.

Remember, it’s the “high probability of imminent deterioration” that often applies to emergency department patients prior to workup and give the coding staff a challenge.  The high “probability of life threatening deterioration” often comes AFTER a diagnostic workup that identifies the extent and type of problem unless it’s obvious at the time of arrival to the ED (loss of consciousness, extreme pain, extreme shortness of breath/hypoxia, etc.).  For example, a patient that presents with shortness of breath may be experiencing a number of problems; acute exacerbation of asthma/hypoxia, impending cardiac arrest, pulmonary embolus, etc.  Prior to further workup, the emergency physician must assess risk factors, chief complaint and presenting problems as well as the overall condition of the patient from a physical examination in order to determine what additional treatment is necessary.

What ultimately determines whether or not the provider considers the problem extreme and potentially life threatening (high probability of imminent deterioration) is the “high complexity decision-making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition”?  The key elements here are “assess, manipulate AND support” to treat and/or prevent further life threatening deterioration of the patient’s condition.

Assessment would include the history, physical and diagnostic workup.  Manipulate would include interventions such as IV/IM/PO medications and/or fluids, surgical procedures, Oxygen, etc.  Support might include much the same as Manipulate with the addition of Observation, Transfer or Admission.

A provider must devote full attention to the patient during critical care time and cannot provide services to any other patient during the exact same time counted toward critical care time.

Critical care time does not have to be continuous – the time may be aggregated. This time may include time spent engaged in work directly related to the patient’s care. It does not have to be spent at the patient’s bedside. Time spent in activities outside of the Department or Unit may not be reported as Critical Care since the provider is not immediately available to the patient.

Critical Care activities which are included in the time, but are not limited to:

  • Assessment and physical examination
  • Obtaining a medical history
  • Documenting the patient’s medical record
  • Interpreting ancillary services such as imaging tests, x-rays, lab work, etc.
  • Consulting with other healthcare providers
  • Talking to the patient
  • Talking to healthcare surrogates, significant others, family when the patient is unable to participate in discussion
  • Performing procedures that are not bundled into Critical Care time

Critical Care can be provided in addition to an E/M service (99281-99285) in limited circumstances.  CMS Transmittal 1473, effective 4/1/08 states, “When a hospital inpatient (or emergency department, or office/outpatient) evaluation and management service (E/M) is furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care, both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service.”

Coding Critical Care and Other Separately Identifiable Procedures

Depending on payer policy, certain separately identifiable procedures performed on a critically ill or injured patient may be billed in addition to Critical Care. Time spent by a provider performing these separately billable services is not included in Critical Care time. Examples of services coded in addition to Critical Care include but not limited to:

  • CPR
  • Intubation
  • Pericardiocentesis
  • Central venous catheter placement
  • Chest tube insertion
  • EKG interpretation

CPT considers the following procedures bundled (included) in Critical Care and therefore not billed by providers in addition to Critical Care. Time spent performing these procedures is included in critical care. In addition to these, Medicare includes CPT codes 93040, 93041 and 93042 (rhythm ECG) in Critical Care time.

In 2017, the following services are included in the delivery of Critical Care:

table4

Provider Statement

It is the responsibility of the provider to document in the medical record the time spent providing critical care to a critically ill or injured patient. The provider must also indicate that Critical Care time does NOT include separately billable services.

For example, the provider would state:

“The patient developed hypotension and hypoxia. I personally spent 35 minutes providing Critical Care to this patient providing fluids, pressor drugs and oxygen. The critical care time does not include time spent performing other separately billed services.”

Critical Care cannot be billed without a provider statement. If the time is not documented, a record should either be sent back to the physician for entry of the time or downcoded to the E/M level consistent with documentation.
Let’s take a look at some objective criteria that may help identify critical care for physicians (as a reminder to add the time statement) and coders who often can’t quite determine if the patient’s condition and/or interventions qualify for Critical Care:

table5

Medical Necessity and Critical Care

We expect to see increasing audits on Critical Care as use of this code continues to increase across the country.  In addition, payers, particularly Medicare, are looking at the ICD-10 diagnosis codes to support the Critical Care services that are billed.  It is important that if your records are audited, you can clearly support the services provided.  Many payer auditors are unfamiliar with how Critical Care in the emergency department differs from the services provided by physicians managing inpatients so it is not uncommon to see Critical Care selected for review.  Consider requiring the following statement on all critical care patients:
“The organ system at risk is…”  I ordered the CT with contrast to rule out a pulmonary embolus on this patient with shortness of breath and severe chest pressure. “

Critical Care – Technical

Billing for the technical component of Critical Care requires the same documentation and elements as outlined above for the professional component.  It stands to reason that if the provider determines that the patient meet the clinical criteria for Critical Care, the same would apply to the technical component.  However, Medicare guidelines for technical billing of critical care are somewhat different and can pose a challenge to hospital coders.  Medicare requires a 30-minute minimum treatment time for Critical Care, “This 30-minute minimum has always applied under the OPPS and will continue to apply . . .”   In addition, the time that qualifies for Critical Care is defined quite differently, “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. (PUB 100-94 MCP, Transmittal 1139, Dec 22,2006)  This means that to qualify for Critical Care for technical ED billing, the record must show detailed documentation of bedside time by nursing staff in order to comply with Medicare policy—something that may be difficult to do but will be necessary if your facility is audited for critical care billing compliance with Medicare regulations.  In general, if the physician enters Critical Care time and/or a statement that indicates that the patient is receiving Critical Care, the technical component should qualify as well FROM A CLINICAL PERSPECTIVE.  However, as the content of physician time is calculated differently, nursing time must indicate one-on-one time at the bedside to meet technical Critical Care requirements for Medicare.

As with professional billing of Critical Care services, hospitals are instructed to follow CPT for inclusive and exclusive procedures.  Recent CMS language indicates time is calculated on face-to-face with patient and ED staff.  There is still general confusion over whether or not CCI edits apply.  The general consensus is that they probably do apply.

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