Ten Commandments of Coding Critical Care in the ER

1. Thou Shalt Know What Defines Critical Care

CPT^® defines Critical Care Services (99291-99292) by three components:

1. A critical illness is an illness or injury in which “one or more vital organ systems” is impaired “such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”
2. A critical intervention involves “high complexity decision making to assess, manipulate, and support vital organ system failure.”

Critical care time is “time spent engaged in work directly related to the individual patient’s care,” whether that time is spent at the immediate bedside or elsewhere on the floor or unit. These criteria assume the physician takes an ongoing and active role in managing that patient’s care. Evidence that the above criteria were met must be present in the medical record with the physician’s attestation that critical care was provided.
Some examples of vital organ system failure include:

• Central nervous system failure
• Circulatory failure
• Shock
• Renal, hepatic, metabolic, and/or respiratory failure

Critical care usually (but not always) is given in a critical care area such as a coronary care unit, intensive care unit, or the ED. Critical care may be provided in any location as long as the care provided meets the definition of critical care. Just because a patient is in the intensive care unit (ICU), does not mean you can code critical care—if the patient is stable, he or she does not meet the criteria for critical care.

2. Thou Shalt Know How CPT^® and CMS Definitions Vary

In July 2008, the Centers for Medicare & Medicaid Services (CMS) released Transmittal 1548, which represents the most recent Medicare payment policy update for critical care services (99291-99292). Regarding critical care for Medicare patients, CMS guidelines state, “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.”
CMS goes beyond the CPT^® description of critical care, adding critical care services must be reasonable and medically necessary … delivering critical care in a moment of crisis, or upon being called to the patient’s bedside emergently, is not the only requirement for providing critical care service. Treatment and management of a patient’s condition, in the threat of imminent deterioration; while not necessarily emergent, is required.”
CMS gives us several examples that may not satisfy the criteria, either because medical necessity was not met, or the patient does not have a critical care illness or injury and is not eligible for critical care payment:

1. Patients admitted to a critical care unit because no other hospital beds were available;
2. 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
3. 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.

Unlike CPT^®, CMS not only requires the illness or injury to be of an urgent or emergent nature, but there be the added inclusion of high-level treatment(s) and interventions to satisfy critical care criteria. CMS criteria for critical care are not met if the emergency physician does not deem pharmacological intervention or another acute intervention (intubation, etc.) as necessary, and if the patient only receives coordination of care and interpretation of studies and is admitted or discharged.
To read Transmittal 1548, along with corresponding MLN Matters articles, go to:
www.cms.hhs.gov/Transmittals/Downloads/R1548CP.pdf and www.cms.hhs.gov/MLNMattersArticles/downloads/MM5993.pdf.

3. Thou Shalt Properly Document Time

The duration of critical care services for CPT^® and Medicare is based on the physician’s documentation of total time spent evaluating, managing, and providing care to the critical patient. Time spent in documenting such activities is included in critical care time. Critical care time does not need to be continuous: Non-continuous time may be aggregated in reporting total critical care time.
To count toward critical care time, the physician must devote his or her full attention to the patient, either at the patient’s immediate bedside or elsewhere on the unit, and the physician must be available to the patient immediately, as necessary. Critical care time also may be spent discussing the patient’s case with staff or discussing with family members (or surrogate decision makers) specific treatment issues when the patient is unable or clinically incompetent to provide history or make management decisions.
Use CPT^® code 99291 to report the first 30-74 minutes of critical care and CPT^® +99292 to report additional block(s) of time up to 30 minutes each beyond the first 74 minutes of critical care. Critical care time less than 30 minutes is not reported using the critical care codes: Such service should be reported using the appropriate E/M code. For example, for critical care time of 35 minutes, report 99291. For critical care time of 115 minutes, report 99291, 99292 x 2.
The critical care clock stops whenever separately-reportable procedures or services are performed. Time spent performing separately-reportable services, or activities that do not directly contribute to the treatment of the critical patient, may not be counted toward the critical care time.

4. Thou Shalt Know the Key Elements

To report 99291/99292, both the illness or injury and the treatment being provided must meet the critical care requirements, as previously described. Clinical reassessments and documentation must support the critical care time aggregated, and should include:

• a description of all of the physician’s interval assessments of the patient’s condition;
• any impairments of organ systems based on all relevant data available to the physician (i.e. symptoms, signs, and diagnostic data);
• the rationale and timing of interventions; and
• the patient’s response to treatment.

5. Thou Shalt Not Report Critical Care in the ER with an E/M Code for a Medicare Patient by the Same Physician on the Same Calendar Day

CMS Transmittal 1548 specifically addresses this situation for the ED, stating when critical care services are required upon arrival in the ED, only critical care codes (99291-99292) may be reported. An ED E/M code (99281-99285), when provided by the same physician (which includes any physician of the same specialty in the same group) to the same patient, may not be reported additionally. Under Medicare rules, however, critical care may be provided on the same day as an inpatient or outpatient E/M service.
For example: A Medicare patient presents to the ED and receives a level five ED workup (99285). Later during the same encounter, the patient deteriorates unexpectedly and requires critical care services. CMS states that the “same” ED physician can only report either the ED E/M service or the critical care service—not both.
To confuse matters, CPT^® allows separate reporting for both an E/M service and a critical care service on the same day; however, CPT^® does not distinguish the site of service or which service comes first. Check with your state’s medical policy and your commercial payers’ medical policy on correct reporting of critical care services to maintain compliance.
Some payers may require modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service to be appended to the same day, non-critical care E/M service, when coded.

6. Thou Shalt Not Bundle

CPT^® and CMS consider several services to be included (bundled) in critical care time when performed during the critical period by the same physician(s) providing critical care. Do not report these services separately. CMS specifies the relevant time frame for bundling to include the entire calendar day for which critical care is reported, rather than limiting the time to just the period the patient is critically ill or injured during that calendar day, as CPT^® does.
Both CPT^® and CMS bundle to critical care the following:

• Interpretation of cardiac output measurements (93561, 93562)
• Pulse oximetry (94760, 94761, 94762)
• Chest X-rays, professional component (71010, 71015, 71020)
• Blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data – 99090)
• Gastric intubation (43752, 91105), Transcutaneous pacing (92953)
• Ventilator management (94002-94004, 94660, 94662)
• Vascular access procedures (36000, 36410, 36415, 36591, 36600)

Any services performed that are not listed above may be reported separately. Physicians are encouraged to document time involved in the performance of separately-reportable procedures. These may not be counted toward critical care time.
For some examples of ER billing and coding go to: http://emcrit.org/190-201/197-ed.billing.htm.

7. Thou Shalt Remember to Code Everything Separately Allowed

The critical care clock stops when performing non-bundled, separately-billable procedures. Some examples of common procedures that may be performed for a critically ill or injured patient include:
92950 Cardiopulmonary resuscitation (eg, in cardiac arrest)
31500 Intubation, endotracheal, emergency procedure
36555 Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age
36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older
36680 Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to vein
32551 Tube thoracostomy, includes water seal (eg, for abscess, hemothorax, empyema), when performed (separate procedure)
33210 Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure)
93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only

8. Thou Shalt Know the Appropriate Use of Modifier 25

CPT^® does not require modifier 25 when billing for critical care services and/or separately billable (non-bundled) procedures; however, CMS and other commercial payers may require modifier 25 on the same day the physician also bills a non-bundled procedure code(s). Check your payers’ medical policies in your state.
For example, for those payers who specify the use of modifier 25 with 99291/99292: If endotracheal intubation (31500) and cardiopulmonary resuscitation (CPR) (92950) are provided, separate payment may be made for critical care in addition to these services if the critical care was a significant, separately-identifiable service and was appended with modifier 25.

9. Thou Shalt Correctly Report CPR and Critical Care During Same Patient Encounter

CPT^® and CMS agree that both CPR (92950) and critical care may be reported, as long as the requirements for each of these services are satisfied and are delineated clearly in the medical record.
CPR encompasses supervising or performing chest compressions, adequate ventilation of the patient (e.g., bag-valve-mask), etc. CPT^® does not list a typical time to qualify CPR as a provided service and qualifies it as a separately-reportable service that may be reported with critical care. Remember: Time spent providing CPR cannot be counted toward calculating total critical care time.

10. Thou Shalt Ensure Teaching Physician Criteria Is Properly Documented

Teaching physicians may tie into the resident’s documentation and may refer to the resident’s documentation for specific patient history, physical findings, and medical assessment when documenting critical care. The teaching physician must include a statement about the total time he or she personally spent providing critical care. The statement must include that the patient was critically ill when the teaching physician saw the patient, why and what made the patient critically ill, and the nature of the treatment and management provided by the teaching physician.
CMS provides the following vignette as an example of acceptable documentation: “Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident’s documentation and I agree with the resident’s assessment and plan of care.”
Note: Time spent alone by the resident performing critical care activities in the absence of the teaching physician is not counted toward critical care time. Only time spent performing critical care activities by the resident and the teaching physician together, or by the teaching physician alone is counted toward critical care time.
Bonus Tip: If There Is Food, Critical Care Isn’t Happening
Critical care has passed when a patient’s septic shock has ended, acute respiratory failure has ended, and if other acute situations are well controlled. If a patient is sitting up and eating a meal and drinking regular beverages, that patient is not critically ill. In any case, you can’t go wrong with strong and supportive documentation, combined with medical necessity that encompasses not just an acute diagnosis, but also emergent interventions.