Wiki Critical Care and Trauma

[dshull81401]

Needing help
I have a question:

If a patient arrives by ambulance with a trauma activation—specifically, a 69-year-old who fell, hit their head, and is on anticoagulants—undergoes a CT scan and labs, and is then sent home, does this scenario qualify for critical care?
The trauma team is asking whether the combination of the trauma activation, the patient's anticoagulant use, and the tests performed would meet the criteria for critical care. Additionally, do you consider documentation beyond the physician's notes when determining if critical care should be coded and charged, especially if the physician does not explicitly document it as critical care?
As a coder, my stance has always been that if the doctor documents the situation as critical care and it meets the necessary criteria, then I will charge and code it as such.

 

[amyjph]

This might help answer questions:

https://www.acep.org/administration/reimbursement/reimbursement-faqs/critical-care-faq

https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00081590

I would also refer back to the CPT guidelines at the beginning of the critical care section. The first paragraph defines it. The second paragraph states these conditions have to be met to qualify. There are specific documentation requirements. It has to be documented by the physician in their notes that they provided critical care and the time and what they did. As a coder, you can't assume or take other parts of the chart to code it. The provider must document it. There are also multiple CPT Assistant references you can check.
Medicare has different time guidelines than CPT.

In your scenario above, those factors alone do not necessarily mean you would report critical care. Did the provider provide and document critical care as defined by ACEP, CPT, and according to their judgement? Maybe. It could be patient dependent. You can't really take a scenario and say it is critical care or not every time. There are exceptions to this of course. Just because it is a trauma activation does not always mean it is.