Wiki Critical Care and ESRD

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I know that organ system failure is essential for coding critical care but I’m having difficulty agreeing with the provider to bill critical care when the only organ failure documented is “severe ESRD” since in this patient the ESRD has been a long established chronic condition. Does anyone have any insight/experience using ESRD to substantiate critical care?
 
The patient’s condition obviously warranted a hospital admission. Was there a high probability of imminent or life-threatening deterioration? If so, it meets the critical care guidelines.
 
I know that organ system failure is essential for coding critical care but I’m having difficulty agreeing with the provider to bill critical care when the only organ failure documented is “severe ESRD” since in this patient the ESRD has been a long established chronic condition. Does anyone have any insight/experience using ESRD to substantiate critical care?

I'd recommend reviewing this Medicare publication which goes into a lot of detail about how CMS views critical care:

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/mm5993.pdf

Both CPT and CMS guidance state that the provider's documentation must reflect "high complexity decision making to assess, manipulate, and support vital system functions to treat single, or multiple, vital organ system failure...You should remember that providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements."

Also of note on page 4, under "scenarios in which a patient’s medical condition may not warrant critical care services", they include an example of an ESRD patient: "Management of dialysis or care related to dialysis for a patient receiving End Stage Renal Disease (ESRD) hemodialysis, unless the critical care is separately identifiable from the chronic long term management of the dialysis dependence."

While the article cited in the post above does support that ESRD may in some instances warrant intensive care services, and renal failure is listed as an example of 'vital organ failure', codes may not be assigned based on this alone. The documentation of the patient's condition and the services rendered are the only source that can validate correct coding.
 
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