Stop Struggling With Critical Care Coding

By Ron Stunz, MD, FACEP
The core requirement defining emergency medicine as a specialty is the ability to carry out critical interventions for patients with organ- or life-threatening illness and injury. Timely interventions in severe infectious, ischemic, traumatic, surgical, and other emergent scenarios have a direct impact on a patient’s outcome. Not so obviously—but only slightly less importantly in the climate of rising and scrutinized health care costs—what is done within the first hour of a patient’s presentation can significantly reduce downstream costs for care.
Providing critical care is the most highly-compensated evaluation and management (E/M) service category for the emergency medicine specialty. Table A shows the relative value units (RVUs) for 2009 emergency medicine E/M levels. Remember E/M coding and billing accounts for 80-85 percent of a typical practice’s revenue stream, and critical care services (99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99292 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes; each additional 30 minutes (List separately in addition to code for primary service)) are reimbursed approximately 25 percent higher than a comprehensive E/M code that might be coded for an uncomplicated hospital admission (99285 Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.).

Table A

Routine Critical Care Too Often Is Unclaimed

Many emergency physicians fail to recognize that they provided critical care. The experienced provider manages serious and complex cases with alacrity and comes to view such activity as routine. A recurrent example is an elderly patient presenting with acute congestive heart failure whose diagnosis is immediately apparent, and whose management may be relatively predicable and formulaic. Too often such a patient’s medical chart does not reflect the time spent in reassessment, discussions with the patient, family members, and consultants, and reviewing studies and prior patient records. The physician does not request critical care coding and billing for the encounter. Similarly, unclaimed critical care scenarios are common for extended emergency department (ED) management of asthma, otherwise healthy young adults with supraventricular tachycardia, or patients with new onset uncontrolled atrial fibrillation.

CPT® Defines Critical Care

CPT® is relatively explicit and detailed in its descriptions of critical care services. Three components are required for codes 99291 and 99292:
1. Critical illness, which “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;”
2. Critical intervention, involving “high complexity decision making to assess, manipulate, and support vital organ system failure;” and,
3. Time, defined as “time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit.”
To code and bill critical care services, documentation supporting all three components of the definition must be present in the medical record, accompanied by the physician’s attestation that critical care was provided.
“Critical illness” may be somewhat problematic and situational in its formal definition, but, as Supreme Court Justice Potter Stewart said on another subject, “I can’t define it, but I know it when I see it.” Emergency physicians are trained and skilled to recognize clinical scenarios in which the patient’s potential for severe clinical deterioration is either actively evolving or imminently likely to occur. Examples cited by CPT® guidelines include, “central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure,” and are usually readily apparent and well-defined clinical scenarios where timely critical intervention is mandatory. Other presentations where overt organ failure has not occurred but there is a high possibility of such failure occurring and the prevention of which requires active physician management are cases in which critical care services are justified and sustainable.
All three verbs CPT® uses to define the provided care, “assess, manipulate, and support,” imply the physician is taking an active role in managing the case, and this should be documented as evidence of therapeutic intervention.

Assess CPT® Gray Areas

Whether cases ending with simple assessment (when therapeutic intervention of the emergency physician is neither feasible nor indicated) meet the requirements of the CPT® definition remains a question in coding and billing circles. For example: An elderly patient presenting with transient neurologic symptoms has the potential for deterioration, although such deterioration generally is not so imminent as to mandate hospital admission in many cases, and therapeutic manipulation may not be prescribed emergently in the ED.
Is the definition of critical care met for a similar patient with evidence of an active ischemic stroke with fixed deficits that the emergency physician does not deem pharmacological intervention warranted or necessary? Although such patients clearly require significant time for coordination of care and interpretation of studies, the absence of manipulative and supportive interventions may argue that critical care was not actively provided. In the absence of active care by the physician, some ambiguity may exist in certain clinical scenarios.
Let’s elaborate on the common scenario of acute ischemic stroke. In the absence of pharmacologic intervention, what distinguishes the case in which critical care services are requested and billed from a similar case coded 99285?
The CPT® descriptor for code 99285 states, “Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.” This certainly is concordant with the presentation of acute ischemic stroke. The medical decision making (MDM) documentation requirement for 99285 must support “high complexity,” a characterization sustainable even when a provider’s therapeutic intervention is absent. As shown in this context, the gradation between a comprehensive level of E/M service and critical care service is ill-defined and open to interpretation both by the provider and the coder.

Factor in Time

Critical Care Services’ time component is an approximation. The physician is not required to carry a stopwatch. Few critical care encounters occur uninterruptedly, and in a busy ED, the physician often has overlapping and conflicting obligations to several patients. An approximation or a range of time spent providing critical care is sufficient for coding and billing purposes.
For 99291, critical care time is defined as 30-74 minutes spent, including direct bedside time, documentation time, discussion time with other medical staff, interpretation of laboratory or imaging studies time, review of old records time, and discussion time about the care of an incompetent or unconscious patient with family members. This time need not be continuous. Recurrent physical reassessments concomitantly occur with critical care and often remain undocumented as bedside time. Brief notes covering these revisits are important not just for accurate coding and billing, but from a medicolegal, risk management perspective.
A number of procedures and services are incorporated into the coding and billing for critical care time and are not billed separately. These include interpretation of chest X-rays, pulse oximetry and blood gasses, passage of a nasogastric tube, temporary pacing, ventilator management, and peripheral vascular access. Procedures not listed specifically as included in CPT®’s Critical Care Services can and must be billed separately.
The two most commonly, separately billable procedures performed for critically ill patients are endotracheal intubation (31500 Intubation, endotracheal, emergency procedure) and the establishment of central venous access (for example, 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older). Note that cardiopulmonary resuscitation (CPR) is also separately billed, and elapsed time during CPR also must be subtracted from the total minutes of critical care time claimed by the provider, along with that of any other separately billable procedure. For example, 60 minutes of total critical care time in which intubation required 5 minutes and the insertion of a central line required another 5 minutes, would equal only 50 minutes of billable critical care time.
Don’t bill critical care for patients under the physician’s care for less than 30 minutes. For example, a patient with a coronary artery lesion who is expedited from the ED to the cardiac catheterization laboratory within 25 minutes of arrival does not qualify as a critical care service, even though such care was provided.
Code 99291 covers minutes 30 to 74 of the patient’s ED time. Subsequent to this time, incremental intervals of 30 minutes are billed using 99292 for each additional half hour. Longer timeframes require progress notes justifying the time spent in direct patient care.
Critical care time documentation requests by the physician should include a statement covering the nature of the illness and a list of the care components requiring the provider’s time. Include a notation that time spent on separately-billable procedures was subtracted from the total time claimed.

Watch for Template Records’ “Cookie Cutter” Effect

Record templates, such as the T-System®, contain acceptable statements covering the documentation requirements. Newer electronic records typically incorporate macros, wherein a single mouse click can generate several sentences covering the critical care services. With all record templates, whether paper or electronic, care must be taken that the documentation is patient-specific, meeting the requirements of medical necessity. The Centers for Medicare & Medicaid Services (CMS) has stated specifically that it looks askance at macro-generated “cookie cutter” medical charts.
Critical care charting is not governed by the same rules that apply to high-level E/M codes. A “comprehensive” E/M service (99285) requires four elements in the history of present illness (HPI), 10 elements in the review of systems (ROS), two of three elements in past medical/family or social history, and eight areas in the physical examination. These component elements are waived for critical care services (99291).

Perform Audits to Ensure Appropriate Compensation

Because critical care is highly compensated, audits from third party payers should be anticipated. Audits may focus on any of the three principal components of critical care services: the severity of the illness, the care provided, or the amount of time claimed by the provider.
Audits typically are triggered by a physician’s relatively high percentage of claims. A skilled coding and billing service, by identifying records where critical care time was provided but was not submitted for, helps assure appropriate physician compensation. This also helps the physician avoid audits by preventing critical care code submission when the medical record does not justify their use. Although well-trained coders are taught to use judgment in critical care services physician claim submission, coders can be influenced by statements from the physician, and may be reluctant or clinically-inexperienced to adjudicate the records containing inappropriate physician requests. Regardless of who codes the record, the provider, under fraud and abuse statutes, bears the ultimate responsibility for the codes submitted.

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