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Thread: critical care in the ER

  1. #1

    Red face critical care in the ER

    AAPC: Back to School
    This one stumped me the other day ....a patient came into the ER with a c/o headache. After a CT , pt was found to be having a stroke. ER really did no emergency interventions...no IV's , nothing beyond basic care and monitoring...watched the pt for a few hours and when an ICU bed became available. pt was moved upstairs. My auditor says that since it was a critical diagnosis..without procedures, pt was still to be coded as "critical care" regardless of interventions or not. PLease let me know what you think of this one. thanks!!!

  2. #2
    Join Date
    Apr 2007
    Louisville, KY


    I'll be blunt: your Auditor is not being prudent in his/her judgment.

    Critical Care, as define in CPT, has specific requirements that must be met; among them,
    * "Critical Care Services"
    (I'm with you, that is not what it sounds like was offered in the ER, at least, not properly documented.)
    * "Providing med.care to a critically ill, injured . . . patient qualifies as a crit care service only if BOTH the illness/injury and the treatments being provided meet the above requirements."
    (I'd ask the auditor to substantiate his/her suggestion that critical, life sustaining services were provided, then slap down that quote out of CPT).
    * You don't mention any time being documented. That would be a requirement for properly coding crit. care services.

    Just my opinion.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

  3. #3


    I like you! You have some great answers for me. I really did not think just a "critical care" diagnosis qualified to charge for critical care. (they were in the er over 30 mins)..close to 3 hours actually had the charting had nothing to indicate they were doing anything but simple monitoring that anyone int he er would get. I currently work in the er 2 days a week and you can tell they were just sitting on this patient until a bed opened up. I mean if they were hanging vasopressors, ona vent ..that's one thing but basic monitoring..even though they may deteriorate in seconds...doesn't mean the er delivered critical care. thanks so much for giving me insight in this..i'll be ready next time!!

  4. #4
    Join Date
    Apr 2007


    when i am auditing critical care notes, the first thing i look for is documentation of time....that is an absolute must. im not referring to the time that nurses or other staff documents--the provider himself has to state specific time or a total time of critical care time. ex. "60 minutes spent in critical care time" or "7:00p-8:00p spent with patient in critical care".
    critical care billing and its requirments are tricky. i would never code something as critical care simply due to the diagnosis.....or, for that matter, just because there was time documented.
    Dawnelle Beall, CPC, CPMA, CPC-I
    Licensed AAPC PMCC Instructor
    AAPC ICD-10CM Certified Trainer

  5. #5


    Hi- without time documentation and procedures documented to justify critical care I would not bill critical care... Alot of times there are critical diagnoses in the ER, but without the documentation you can't bill for them... I agree, sounds like they were just waiting for a bed to open up...

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