Keep track of your “critical care clock” when providing different levels of care by Kristy Welker, CPC
Published in the July 2007 issue of Today's Hospitalist.
Consider this scenario, which may be common for many of you: You admit a patient with septic shock and then proceed to provide critical care, giving the patient gastric intubation and providing ventilator management.
So what do you bill for admission, and what do you bill as critical care? Determining how critical care services tie into billing for other types of services and hospital visits can be tricky.
You need to know, for instance, what services constitute critical care. You also need to watch the clock when providing critical care, because those services—unlike many
Time spent should be your guiding principle when documenting and billing for critical care services.
other E/M services—are billed based on the total amount of time you spend performing them.
Then there’s another wrinkle: Many critical care services can’t be billed separately. However, the time you spend providing those services counts toward the total time you can bill.
Defining critical care
Critical care is defined as physicians’ direct delivery of medical care for a critically ill or unstable patient.
A critical illness acutely impairs one or more vital organ systems, so that a patient’s condition has a high probability of imminent or life-threatening deterioration. Note that, according to this definition, patient deterioration—not death—is imminent.
Examples of conditions that generally qualify for critical care include central nervous system failure; circulatory failure; shock; or renal, hepatic, metabolic and/or respiratory failure.
You use one of the following codes to bill for critical care services:
• 99291: Critical care, evaluation & management; first 30-74 minutes
• 99292: Critical care, each additional 30 minutes
Note that you must spend at least 30 minutes attending to the patient, which does not mean providing continuous attention at the bedside. Instead, the amount of time you can bill includes all of the following:
• time spent at the bedside with the patient;
• time spent on activities that contribute to the patient’s care, such as reviewing old records and lab and imaging results, as well as consultations with other physicians; and
• time spent with family, whether to obtain a history or to discuss treatment options when a patient is not able to participate.
Performing any of the following services also counts as part of your time providing critical care:
Keep in mind that you can't bill separately for the above services, but you should keep your critical care time clock ticking while you perform them. Other services not listed above that are commonly provided during critical care, such as CPR, may be billed separately. Just make sure that you do not count the time spent performing them toward your total critical care time.
Time spent also needs to be your guiding principle in documenting critical care services. If you do not document the total time spent providing critical care, you cannot use critical care codes, which are billed at substantially higher rates than other E/M service codes.
Complex billing cases
Now that we’ve covered the basics, let’s go back to the scenario we described at the beginning of the article.
Say you admit Mr. Jones on day 1 with septic shock. His blood pressure is unstable and he needs gastric intubation, so the admission takes three hours.
You would code 99223 for the admission and also bill for your critical care services. Be sure to subtract the time you spend performing admission functions, such as a history and physical, from what you count as critical care time.
Calculate that critical care time—which, again, does not have to be continuous—by adding up all the time you spent stabilizing the patient to prevent an imminent or life-threatening deterioration. That would include the time spent performing the gastric intubation.
What about vent management (94656)? Say that, for this patient, you set the initial vent settings and check blood gases to make sure they are appropriate. Would you code separately for these services and subtract out the time you spent performing them from your critical care time?
The answer is that vent management is included with critical care and is not separately billable. But just like with gastric intubation, keep your critical care clock ticking while performing vent management. That time counts toward your total critical care time.
Other services, other physicians
Let’s say a code is called for Mr. Jones on day 2 and CPR (92950) is performed. You run the code and order further CPR, which is maintained for 31 minutes. The entire episode takes 90 minutes of physician time, either at the bedside or at the nurse’s station. What codes should you bill now?
You can bill a critical care code (99291) and a CPR code (92950). You would exclude the 31 minutes spent performing CPR from your total critical care time.
What if you also perform a hospital visit for Mr. Jones that same day? You should bill that visit as a subsequent care E/M level code (92331-99233), and you should bill for the 59 minutes of critical care time (99291) and CPR (92950).
Finally, take that same situation and add yet another service: Later that day, another physician from your group comes on shift and performs 30 additional minutes of critical care. Are those minutes billable?
As I discussed in my May 2007 article, if your group has different doctors of the same specialty who see the same patient over the course of any given day, all the E/M services provided by hospitalists in your group to that patient should be billed under one doctor. You would definitely bill for the additional 30 minutes of critical care provided by your colleague. But those services would most likely be billed by you because you provided the majority of services to that patient on that day.
Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at email@example.com. We'll try to answer your questions in a future issue of Today's Hospitalist.
A partial list of diagnoses that support critical care services
• Acute cardiac complications, such as arrest, insufficiency or failure, during or following a procedure
• Acute respiratory distress
• Air embolism
• Amniotic fluid embolism
• Anaphylactic shock
• Cardiac arrest
• Cardiogenic shock without mention of trauma
• Failed attempted abortion complicated by shock
• Fat embolism
• Illegally induced abortion complicated by shock
• Legally induced abortion complicated by shock
• Malignant hypothermia or hyperpyrexia due to anesthesia
• Obstetrical blood clot embolism
• Respiratory arrest
• Shock due to anesthesia
• Shock following abortion and ectopic and molar pregnancies
• Shock, including hypovolemic and septic, without mention of trauma
• Shock, unspecified without mention of trauma
• Spontaneous abortion complicated by shock
• Traumatic shock
• Unspecified abortion complicated by shock
• Ventricular fibrillation