Critical care is the direct delivery by a physician(s) of medical care for a critically ill or injured patient.
- The care of such patients involves decision making of high complexity to assess, manipulate, and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple vital organ system failure or to prevent further deterioration.
- It may require extensive interpretation of multiple databases and the application of advanced technology to manage the patient.
- Critical care services include but are not limited to, the treatment or prevention or further deterioration of central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, postoperative complications, or overwhelming infection.
In order to reliably and consistently determine that delivery of critical care services rather than other evaluation and management (E/M) services is medically necessary, both of the following medical review criteria must be met in addition to the Current Procedural Terminology (CPT) Manual definitions:
- Clinical condition criterion – There is a high probability of sudden, clinically significant, or life-threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently.
- Treatment criterion – Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or 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.
Reporting of Provider’s Time Spent in Critical Care Service
Since critical care is a time-based code, the physician’s progress note must contain documentation of the total time involved providing critical care services. Critical care codes 99291 (evaluation and management of the critically ill or critically injured patient, first 30-74 minutes) and 99292 (critical care, each additional 30 minutes) are used to report the total duration of time spent by a provider providing critical care services to a critically ill or critically injured patient, even if the time spent by the provider on that date is not continuous.
For any given period of time spent providing critical care services, the provider must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time. The time involved performing procedures that are not bundled into critical care (i.e., billed separately) may not be included and counted toward critical care time.
The provider’s progress note must document that time involved in the performance of separately billable procedures was not counted toward critical care time. The time involved with family members or other surrogate decision-makers, whether to obtain a history or to discuss treatment options may be counted toward critical care time only when:
- The patient is unable or incompetent to participate in giving history and/or making treatment decisions,
- The discussion is absolutely necessary for treatment decisions under consideration that day, and
- All of the following are documented in the provider’s progress note for that day:
- The patient was unable or incompetent to participate in giving history and/or making treatment decisions, as appropriate,
- The necessity of the discussion (e.g., no other source was available to obtain a history” or “because the patient was deteriorating so rapidly needed to discuss treatment options with the family immediately”),
- The treatment decisions for which the discussion was needed, and
- The substance of the discussion as related to the treatment decision.
- The physician’s progress note must link the family discussion to a specific treatment issue and explain why the discussion was necessary on that day.
- All other family discussions, no matter how lengthy, may not be counted towards critical care time.
Reporting Critical Care Services
CPT code 99291 (evaluation and management of the critically ill or critically injured patient, first 30-74 minutes) to report the first 30-74 minutes of critical care on a given calendar date of service. You can only use this code once per calendar date to bill for care provided for a particular patient by the same physician or physician group of the same specialty.
CPT code 99292 (critical care, each additional 30 minutes) is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care. Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E/M code such as subsequent hospital care.
Whether it’s using correct CPT codes or documenting medical necessity or documenting time, critical care billing and coding is a challenging task. Partnering with an experienced critical care medical billing service provider is a practical way to ensure accurate reporting and avoid audits. To know more about our critical billing and coding services, contact us at can contact us at 888-357-3226/ firstname.lastname@example.org