Critical Care Services and Medical Necessity

Critical care services must be medically necessary and reasonable. Services provided that do not meet critical care services or services provided for a patient who is not critically ill or injured in accordance with the above definitions and criteria but who happens to be in critical care, intensive care, or other specialized care units should be reported using another appropriate E/M code (e.g., subsequent hospital care, CPT codes 99231 – 99233).

Critical care services encompass both treatments of ‘vital organ failure’ and ‘prevention of further life-threatening deterioration of the patient’s condition.’ Therefore, although critical care may be delivered in a moment of crisis or upon being called to the patient’s bedside emergently, this is not a requirement for providing critical care service. The treatment and management of the patient’s condition, while not necessarily emergent, shall be required, based on the threat of imminent deterioration (i.e., the patient shall be critically ill or injured at the time of the physician’s visit).

Examples of patients whose medical condition may not warrant critical care services:

  • Daily management of a patient on chronic ventilator therapy does not meet the criteria for critical care unless critical care is separately identifiable from the chronic long term management of the ventilator dependence.
  • Management of dialysis or care related to dialysis for a patient receiving ESRD hemodialysis does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the dialysis dependence (refer to Chapter 8, §160.4). When a separately identifiable condition (e.g., management of seizures or pericardial tamponade related to renal failure) is being managed, it may be billed as critical care if critical care requirements are met. Modifier –25 should be appended to the critical care code when applicable in this situation.
  • Medical Scenario 1: An 81-year-old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent.
  • Medical Scenario 2: A 67-year-old female patient is 3 days status post mitral valve repair. She develops petechiae, hypotension, and hypoxia requiring respiratory and circulatory support.
  • Medical Scenario 3: A 70-year-old admitted for right lower lobe pneumococcal pneumonia with a history of COPD becomes hypoxic and hypotensive 2 days after admission.
  • Medical Scenario 4: A 68-year-old admitted for an acute anterior wall myocardial infarction continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy.

Examples of patients who may not satisfy Medicare medical necessity criteria, or do not meet critical care criteria, or who do not have a critical care illness or injury and therefore not eligible for critical care payment:

  • Patients admitted to a critical care unit because no other hospital beds were available;
  • Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose); and
  • Patients admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit.

Providing medical care to a critically ill patient should not be automatically deemed to be a critical care service for the sole reason that the patient is critically ill or injured. While more than one physician may provide critical care services to a patient during the critical care episode of an illness or injury each physician must be managing one or more critical illnesses or injuries in whole or in part.

For example, a dermatologist evaluates and treats a rash on an ICU patient who is maintained on a ventilator and nitroglycerine infusion that is being managed by an intensivist. The dermatologist should not report service for critical care. Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care.


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