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The truth behind some common myths about how to use critical care codes
Because those codes are slightly different from E/M codes, there’s confusion about how to use them
by Tamra McLain, CPC, CPC-H, CMC



Published in the August 2006 issue of Today's Hospitalist

Critical care services are a special set of codes reserved for patients who are deemed critically ill or injured. But because there are so many misconceptions about exactly when to use these codes, I thought it would be helpful to address some of the fallacies of billing for critical care services.

Let’s start with the definition given by CPT. Those guidelines say that it is appropriate to use critical care codes when physicians are involved in the direct delivery of medical care to a patient who has sustained an injury or illness that impairs a vital organ system that could amount to life-threatening deterioration.

That may seem like a fairly comprehensive definition, but there are a few other things you need to know to make sure you’re using critical care codes appropriately.

While it’s essential to consider the condition of the pa¬tient, you also need to track the total amount of time you spend stabilizing the patient. Once you start the clock for critical care services, you must devote all of your time to that particular patient. The second you walk away and stop caring for that patient, the clock stops for critical care.

If you note start and stop times in the medical record instead of total duration of time spent with the patient, you need to make sure that you convert these start and stop times into a lump sum of time when reporting CPT codes.

Dispelling myths

Let’s address some of the myths about critical care services. First, you don’t necessarily have to be at the bedside when delivering critical care services. Coordinating care with other providers, re¬viewing and ordering labs and tests, and discussing a prognosis with family can all count toward critical care services.

Another myth says that the location of the patient deter¬mines your ability to report critical care codes, but that’s simply not true. This is a fallacy that too many physicians fall prey to.

While physicians may mistakenly believe that their pa¬tient must be in the emergency room or critical care unit for the codes to apply, the truth is that these codes can ap¬ply anywhere within the hospital. In addition, they are not limited to a certain specialty.

Another fallacy? Physicians must meet certain levels in history, exam and medical decision-making before they can use critical care codes.

While this is true with evaluation and management services, it is not the case with critical care. The main idea that you need to communicate in the medical record is the jeopardy of the patient and the amount of time spent stabilizing the patient’s condition.

The test of time

The mention of evaluation and management codes brings up a question that I hear all the time: Can a physician ever report an initial visit or subsequent visit and a critical care code on the same day? While this scenario is relatively unusual, it is a possibility, at least in the inpatient arena.

Consider the following scenario: During rounds, a normal follow-up visit is documented that meets the necessary elements of history, exam and medical decision-making. The patient is suffering from pneumonia and has a history of congestive heart failure, and later that that day, he goes into acute respiratory failure and you find yourself back with the patient stabilizing a vital organ system.

In this case, you can bill for both an evaluation and management service (the morning rounds) and the critical care service (stabilizing the patient after acute respiratory failure).

This is where the element of time plays an important role in determining which code to use. CPT tells us that physicians must perform services for between 30 minutes and up to 74 minutes to meet the requirements of critical care code 99291. If you spend more time, you should use code 99292 to report every additional 30 minutes. If you spend less than 30 minutes, the guidelines say, you should use an E/M code. (See “How to report the time you spend on critical care services,” on left)

In the above scenario, remember to use a -25 modifier with the regular E/M code. That will indicate that you provided a distinct E/M service in addition to the critical care service.

In addition, always make sure the diagnosis codes you choose for either E/M services or critical care services re¬flect medical necessity.





Separate services

CPT guidelines say that when using critical care codes, certain services are an inherent part of stabilizing a critically injured or ill patient and should not be reported separately. That list includes the following services:
• interpretation of cardiac output measurement (93561 or 93562);
• chest X-rays (710,10 71015, 71020);
• pulse oximetry (94760, 94761, 94762);
• blood gases;
• gastric intubation (43752, 93562);
• temporary transcutaneous pacing (92953);
• ventilator management (94656, 94657, 94660, 94662); and
• vascular access procedures (36000, 36410, 36415, 36540, 36600).

There are other procedures, however, that you can report separately, even if you’ve already billed for a critical care service. Those include common inpatient procedures like lumbar punctures, arterial lines, central venous lines and intubations.

Remember to modify the critical care code to reflect medi¬cal necessity and distinguish it from the procedure. If you spend any time on separately billable procedures, don’t re¬port that time in the total duration of critical care time. That will be considered fraud and abuse if you’re ever audited.

Finally, attending physicians practicing in a teaching environment must only report their time, not that of students or residents.

Tamra McLain is an independent coding consultant in southern California. E-mail your documentation and coding questions to her, or send a fax to 888-202-1601. We’ll answer your questions in a future issue of Today’s Hospitalist.



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