Emergency physicians are frequently at the forefront of critical care, often making life-saving interventions in the most acute situations. Consider a typical Monday morning in the Emergency Department (ED): paramedics rush in with a patient experiencing a STEMI, and the cardiac catheterization team swiftly takes over. “Another seamless resuscitation,” you might think, noting the patient was in and out of the ED in under 20 minutes. You diligently document 20 minutes of critical care time and move on to the next patient. However, weeks later, you receive a chart correction flagging an error in your critical care time documentation. The coding department informs you the visit will be billed as a Level 3 E/M visit (code 99283). What went wrong? Understanding the nuances of critical care charting and coding, especially in the fast-paced ED environment, is crucial. This guide, drawing upon insights from ALiEM (Academic Life in Emergency Medicine), will clarify the essential elements for accurate critical care documentation and billing, ensuring you receive appropriate reimbursement for the life-saving care you provide.
Defining Critical Care in the Emergency Department: CMS Criteria
The Centers for Medicare & Medicaid Services (CMS) has specific criteria that must be met to justify critical care billing. According to CMS, critical care is warranted when a patient presents with a medical condition that “impairs one or more vital organ systems” and “there is a high probability of imminent or life-threatening deterioration in the patient’s condition.” Furthermore, the physician must provide “frequent personal assessment and manipulation” of the patient’s condition. While conditions like cardiac arrest, severe trauma, and situations requiring ICU admission clearly qualify, many other ED encounters also meet these criteria. Emergency physicians routinely manage a wide array of conditions and perform numerous interventions that can justify critical care billing. It’s important to recognize these opportunities to ensure accurate and appropriate coding.
Table 1: Common Conditions and Interventions Frequently Associated with Critical Care Billing in the ED
This table, adapted from ACEP guidelines, highlights conditions and interventions that often align with critical care billing. Recognizing these can help you identify situations where critical care coding is appropriate.
Time-Based Critical Care Billing: A Key Differentiator
Critical care billing differs significantly from standard Evaluation and Management (E/M) coding, particularly in its emphasis on time. Accurate and clear documentation of time spent providing critical care is mandatory and is billed using specific codes. Unlike typical E/M coding, where the level of service is determined by elements like history, exam, and medical decision-making, critical care billing is primarily driven by time spent. To bill for critical care, emergency physicians must dedicate at least 30 minutes or more to the patient’s critical care.
Table 2: CPT Codes for Critical Care Time
| CODE | SERVICE |
|---|---|
| 99291 | Reporting the first 30-74 minutes of critical care on a given day. Critical care time less than 30 minutes is billed using standard E/M codes. |
| 99292 | Used in addition to 99291 for each additional 30 minutes beyond the initial 74 minutes of critical care. |
| G0390 | Added to 99291 for Trauma Team Activation when specific criteria are met at designated trauma centers. |
Both direct and indirect patient care activities count towards critical care time. This includes a broad spectrum of activities such as patient evaluation, communication with EMS and family, interpreting diagnostic studies (like X-rays and labs), consultations with specialists, chart review, and documentation. Even time spent on bundled procedures is included. However, it is crucial to remember that time spent on procedures that are billed separately cannot be included in critical care time calculations.
Table 3: Bundled vs. Separately Billed Procedures in Critical Care
| Procedures Bundled into Critical Care Time | Procedures Billed Separately from Critical Care |
|---|---|
| Interpretation of cardiac output, chest x-rays, pulse oximetry, blood gases, computer data | Endotracheal intubation |
| Gastric intubation (e.g., nasogastric tubes) | Central venous access |
| Temporary transcutaneous pacing | Intraosseous line placement |
| Ventilatory management | Transvenous pacing |
| Blood draws | Chest tube insertion |
| Peripheral IV access | CPR |
| Wound care (simple) | Electrical cardioversion |
| ECG interpretation | |
| Electrical defibrillation |
While meticulous timing with a stopwatch isn’t necessary, accurate tracking and documentation of total critical care time is essential. Key points to remember about critical care time are:
- It is cumulative, meaning it’s the total time spent, not necessarily continuous.
- It can be billed only once per physician, per patient, per day.
- It doesn’t need to be continuous; time spent can be accumulated throughout the ED visit.
- Critical care time requires direct involvement and documentation by an attending physician. Resident physician time alone, without attending involvement and documentation, is not reimbursable under critical care codes.
Attending Physician Attestation: Ensuring Compliant Documentation
To ensure proper billing compliance, attending physicians must clearly document their personal involvement in critical care cases. An attestation note should reflect their direct participation in the patient’s care. A sample attestation note might include elements like:
“I have discussed this critical case with the resident/mid-level provider. I personally performed a history and physical exam and made independent medical decisions regarding the patient’s care. I have reviewed the resident’s/mid-level provider’s note and concur with the findings and plan, except for [specify exceptions, if any].
Based on my evaluation, this patient presented with a high probability of imminent or life-threatening deterioration due to [specify critical condition], necessitating my direct attention, intervention, and personal management.
I have personally provided [Number] minutes of critical care, excluding time spent on separately billable procedures. This time includes review of laboratory data, radiology results, discussions with consultants, and continuous monitoring for potential decompensation. Interventions were performed as documented in the medical record.”
– [Attending Physician Initials and Time Stamp]
This type of attestation clearly demonstrates the attending physician’s direct involvement and justifies critical care billing.
Essential Elements of Critical Care Time Documentation in the ED Chart
Comprehensive documentation is paramount for justifying critical care billing. Your chart must clearly articulate why the patient met CMS criteria for critical care. To achieve this, ensure your documentation explicitly addresses the following:
- Patient’s Critical Illness: Detail how the patient met the criteria for critical illness, specifying the organ system dysfunction and the high probability of imminent deterioration.
- Interventions Provided: Clearly outline all interventions performed for the patient’s critical condition.
- Cumulative Critical Care Time: Document the total cumulative time spent on both direct and indirect critical care activities.
Furthermore, consider documenting these specific points when relevant to strengthen your critical care justification:
- Severity of Illness and Decompensation Risk: Emphasize the severity of the patient’s condition and the potential for rapid decompensation.
- Vital Signs and Trends: Document abnormal vital signs (hypotension, hypoxia, etc.) and how these vital signs changed in response to your interventions throughout the ED course.
- Diagnostic Testing and Interpretation: Record all tests performed and your interpretation of the results, highlighting how these results contributed to your critical care management.
- Treatments Administered: Document all treatments provided, including oxygen therapy, intravenous fluids, medications (especially vasoactive drips, insulin infusions, or ACLS medications), blood transfusions, and wound care.
- Procedures Performed: List all procedures undertaken, differentiating between bundled and separately billable procedures for accurate time accounting.
- Patient Re-assessments: Document frequent re-assessments of the patient’s status and their response to your interventions, demonstrating ongoing critical care management.
- Communication and Coordination: Record conversations with EMS personnel, the patient, family members or surrogate decision-makers, nursing home staff, consultants, and admitting teams, as these contribute to indirect critical care time.
- Chart Review and Impact on Care: Note any information retrieved from chart review and how this information directly impacted your critical care management decisions.
It’s important to note that these critical care documentation guidelines differ from standard E/M coding guidelines for non-critical patients. A chart coded for critical care will not have a separate E/M level assigned, as these coding systems are mutually exclusive. However, if your critical care documentation falls short of CMS standards, or if the documented critical care time is less than 30 minutes, the chart will be billed according to standard E/M codes. Therefore, if there’s any uncertainty about meeting critical care criteria, it’s prudent to also document elements that support standard E/M coding levels.
Revisiting the STEMI Case: Time is of the Essence
Let’s return to the initial case of the STEMI patient rapidly transferred to the cath lab. While the patient undoubtedly met the CMS criteria for organ system dysfunction and high risk of decompensation, the critical factor for appropriate billing hinges on documented time. If, despite the critical nature of the presentation, the provider spent less than 30 minutes of cumulative direct and indirect critical care time, critical care billing (codes 99291, 99292) is not justified. In such cases, as with our STEMI example, the visit defaults to being billed using standard E/M codes, potentially at a lower level, such as a Level 3 visit (99283). This underscores the critical importance of accurately documenting not only the critical nature of the patient’s condition but also the time spent providing critical care. If there is any doubt that a case will reach the 30-minute critical care threshold, ensure your documentation also supports appropriate E/M coding levels to ensure proper reimbursement for the services provided.
Workflows for Efficient and Accurate Critical Care Charting in the ED
- Recognize Critical Care Opportunities: Emergency physicians frequently provide critical care without realizing they meet billing criteria. Reflect on your daily practice and identify potential missed critical care billing opportunities. Conditions and interventions listed in Table 1 can serve as a helpful reminder.
- Prioritize Medical Decision Making Documentation: Critical care charting doesn’t necessitate the detailed history and physical exam elements required for E/M level billing in non-critical care cases. Leverage this by focusing your documentation efforts on the medical decision-making aspect of the chart. Clearly articulate how the patient was critically ill, what you did to manage their condition, and how much time you spent providing critical care.
- Utilize Macros and Templates: Employing macros or pre-built templates within your Electronic Health Record (EHR) can significantly streamline critical care documentation. Templates can prompt you to document essential elements efficiently, ensuring comprehensive and compliant charting in a timely manner.
By understanding and implementing these principles of ALiEM ED charting and coding for critical care, emergency physicians can ensure accurate documentation and appropriate reimbursement for the vital, life-saving care they deliver every day.
Further Resources
ALiEM ED Charting and Coding Series
Kenneth Dodd, MD
Emergency Medicine-Internal Medicine Chief Resident Critical Care Fellow Hennepin County Medical Center
Ted Fan, MD
Ted Fan, MD
Emergency Medicine Chief Resident Department of Emergency Medicine George Washington University
