Cardiology Coding Alert

Question: A patient with chest pain “coded” in the ER and the cardiologist admitted her to the ICU. The cardiologist then saw the patient for a cardiology consult. Can we charge for critical care since the patient was in the ICU?

Answer: No. You can’t bill critical care (99291-99292, Critical care, evaluation and management of the critically ill or critically injured patient ...) simply because the place of service is the intensive care unit (ICU).

The service you describe is an inpatient consultation, like 99253 (Inpatient consultation for a new or established patient ...). For Medicare or other payers not accepting consultation codes, this would constitute an initial hospital care code such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...).

Essential distinction: Critical care is not location-based. It describes a specific kind of care.

Critical care occurs when a physician or other qualified healthcare professional directly provides medical services for a critically ill or critically injured patient. As always, the documentation must support the necessity of the critical care service.

To qualify for critical care, a service must meet the following requirements:

• The patient must be critically ill/injured — have vital organ failure or a life-threatening health condition.
• The physician must perform the critical care services, including using high-complexity decision making to assess, manipulate, and support vital system functions to treat vital organ system failure or to prevent further life-threatening conditions.
• All critical care services must last at least 30 minutes on a given date of service. The time can be continuous or intermittent. But, for any given period of time the physician spends providing critical care services for a patient, he cannot provide services to any other patient during the same period of time.