AAPC - Back to school
Results 1 to 5 of 5

Thread: Critical Care - Hello everyone

  1. #1

    Default Critical Care - Hello everyone

    AAPC: Back to School
    Hello everyone, I have a scenario that is really confusing to me. My physician was called into the ER to see a patient that was feeling weak. The patient has a history of anemia, CHF, and CKD. My physician is a Nephrologist and treats the patient for the anemia and CKD. If the patient was not in critical care due to those diagnosis but my physician was called to evaluate those diagnosis would this be critical care?

    In short I want to know if a patient has a history of chronic illnesses can we bill critical care if the chronic illness isn't the reason the patient is in critical care?

    Please help.

  2. #2
    Join Date
    Apr 2007
    Dover Seacoast New Hampshire


    Please take a look at both CMS's and CPT's descriptions of critical care. Both will outline the documentation criteria (time), as well as the guidelines regarding the patient status.

    Critical care can take place anywhere, not just in the ICU. It has to do with the patient's condition and the intensity and degree of treatment given, not the location of the patient at the time. Typically the situation is life threatening, either from organ failure or acute trauma, but other scenarios can also apply, if clearly documented.

    It's not that I don't want to give you the complete answer.....but one of my very best coding colleagues, who helped train me in this field, used to tell me, "Look it up, you'll remember it better than if I tell you".

    send me a PM if you have questions. Pam
    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default Check the guidelines

    In order to bill critical care codes:
    1) the patient must be critically ill (at this encounter)
    2) the service provided must be critical care
    3) a minimum of 30 minutes of direct face-to-face time must be spent provided critical care, and so documented.

    You said the patient was not critically ill. I think you answered your own question.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4


    When I did the research it didn't appear to be critical care to me because the patient was "in no acute distress" per the physician's own note when he saw the patient. His rational is that he treats the patient for chronic conditions and that's why it was critical care and just because the patient was "in no acute distress" when he saw him doesn't mean that he wasn't critical, his problem had subsided at the time. My rationale is that although the patient has chronic conditions, the chronic conditions was not the reason for the ER visit and the ER doctor called him because he saw that the patient had ESRD and my physician is his Nephrologist. Who is right?????

  5. #5


    You would bill a regular E/M visit. If the patient was admitted to the hospital, bill an inpt code, if they were released from the ER bill an outpt code. If the ER physician was actually requesting a consult from your doc, bill a consult code.

    As for what is considered critical, it would be anything that acutely 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. CPT has listed the following as some examples of what would be considered critical:

    • Central nervous system failure
    • Circulatory failure
    • Shock
    • Renal Failure
    • Hepatic Failure
    • Metabolic Failure
    • Respiratory Failure

    In addition, 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. While this patient has ESRD, he was stable during this visit so I don't think his overall condition was critical.

    Also remember though, critical care can only be reported once a day so if another service is actually treating the more critical condition (like an actual ICU physician) then your nephrologist should probably not use this code anyway.

    Hope that all made sense and didn't make it worse

    Lisi, CPC
    Last edited by lisigirl; 03-23-2010 at 05:09 PM.

Similar Threads

  1. E&M Critical Care and Subsequent Hospital Care
    By abbyakinleye in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 04-10-2016, 01:51 PM
  2. Replies: 2
    Last Post: 05-18-2012, 04:01 PM
  3. Replies: 11
    Last Post: 02-21-2011, 11:06 AM
  4. Replies: 4
    Last Post: 10-19-2010, 09:37 AM
  5. Newborn Care and Neonate/Pediatric Critical Care
    By bobbro in forum Pediatrics
    Replies: 1
    Last Post: 03-03-2009, 03:35 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.