The Ten Commandments of Critical Care Coding in the ER: AAPC Guidelines

Emergency department (ED) physicians frequently provide critical care services, and accurately coding these services is crucial for proper reimbursement and compliance. As a Certified Professional Coder (CPC®) specializing in emergency medicine, I often encounter questions about the nuances of critical care coding in the ED. To simplify this complex topic, I’ve developed these ten commandments to guide you through the intricacies of critical care coding in the emergency room, aligned with AAPC (American Academy of Professional Coders) guidelines and industry best practices.

1. Thou Shalt Know What Defines Critical Care

To correctly code critical care services (CPT® codes 99291-99292), you must first understand the fundamental definition. According to CPT®, critical care services are defined by three core components:

1. Critical Illness or Injury: The patient must be critically ill or injured. This is defined as an illness or injury that impairs “one or more vital organ systems” and has a “high probability of imminent or life-threatening deterioration in the patient’s condition.” This signifies that without immediate and intensive intervention, the patient’s condition is likely to worsen significantly, potentially leading to death.

2. Critical Intervention: The physician’s involvement must include “high complexity decision making to assess, manipulate, and support vital organ system failure.” This goes beyond routine care and necessitates complex medical judgment to manage the failing organ system(s). These interventions are aimed at preventing further deterioration and stabilizing the patient’s condition.

3. Critical Care Time: This refers to the “time spent engaged in work directly related to the individual patient’s care,” whether at the immediate bedside or elsewhere on the floor or unit. This time must be dedicated solely to the critical patient and their care management. The physician must be actively involved in managing the patient’s condition throughout this time.

Crucially, the medical record must contain clear evidence that these criteria are met, along with the physician’s explicit attestation that critical care was indeed provided. This documentation serves as the foundation for justifying the use of critical care codes. Examples of vital organ system failure include, but are not limited to:

• Central nervous system failure (e.g., coma, seizures)
• Circulatory failure (e.g., profound hypotension, cardiogenic shock)
• Shock (e.g., septic, hypovolemic, anaphylactic)
• Renal, hepatic, metabolic, and/or respiratory failure (e.g., acute kidney injury, liver failure, diabetic ketoacidosis, acute respiratory distress syndrome)

While critical care is often delivered in specialized areas like coronary care units (CCUs), intensive care units (ICUs), or the ED, the location is not the determining factor. Critical care can be provided in any setting, as long as the services rendered meet the CPT® definition. Conversely, simply being in an ICU or ED does not automatically qualify as critical care. If a patient is stable and does not meet the criteria of critical illness and requiring critical interventions, critical care coding is not appropriate, even within a critical care unit.

2. Thou Shalt Know How CPT® and CMS Definitions Vary

It’s essential to understand the nuances between CPT® guidelines and the Centers for Medicare & Medicaid Services (CMS) definitions, especially when coding for Medicare patients. CMS Transmittal 1548, released in July 2008, outlines Medicare’s payment policy for critical care services (99291-99292). CMS guidelines build upon the CPT® definition and emphasize the urgency and medical necessity of the interventions.

According to CMS, “the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration in the patient’s condition.” This highlights the time-sensitive nature of critical care for Medicare patients. Furthermore, CMS stresses that critical care services must be “reasonable and medically necessary.” This means that not only must the patient be critically ill, but the interventions provided must be medically appropriate and essential for managing their condition.

CMS provides examples of situations that may not meet critical care criteria, even if provided in a critical care setting:

1. Bed Availability: Patients admitted to a critical care unit solely because no general hospital beds are available. The critical care unit should be reserved for patients needing critical care, not just any available bed.

2. Routine Monitoring: Patients admitted for close nursing observation and/or frequent vital sign monitoring, such as in cases of drug toxicity or overdose, where critical organ system failure is not imminent. While these patients need careful monitoring, it doesn’t automatically equate to critical care.

3. Hospital Policy: Patients admitted to a critical care unit because of hospital rules mandating certain treatments (e.g., insulin infusions) to be administered in that unit. Critical care coding should be based on the patient’s clinical status, not administrative policies.

Unlike CPT®, CMS criteria require not only an urgent or emergent condition but also “high-level treatment(s) and interventions” to qualify as critical care. If an emergency physician determines that pharmacological intervention or acute interventions like intubation are not necessary, and the patient primarily receives coordination of care and interpretation of studies before admission or discharge, CMS criteria for critical care are generally not met.

For detailed information, refer to CMS Transmittal 1548 and related MLN Matters articles available at: www.cms.hhs.gov/Transmittals/Downloads/R1548CP.pdf and www.cms.hhs.gov/MLNMattersArticles/downloads/MM5993.pdf. Understanding these distinctions is vital for accurate coding, particularly when dealing with Medicare patients.

3. Thou Shalt Properly Document Time

Accurate documentation of time is paramount for reporting critical care services under both CPT® and Medicare guidelines. The duration of critical care is based on the total time the physician spends actively involved in evaluating, managing, and providing care to the critically ill patient. Crucially, time spent documenting these activities is also included in critical care time.

Critical care time does not need to be continuous. Non-continuous time intervals can be aggregated to calculate the total critical care time. To be counted, the physician must be fully engaged in the patient’s care, either at the bedside or elsewhere on the unit, and must be immediately available to the patient as needed.

Furthermore, critical care time can include time spent:

• Discussing the patient’s case with staff: Collaborating with nurses, specialists, and other healthcare professionals is an integral part of managing critical patients.
• Discussing treatment with family members or surrogate decision-makers: When the patient is unable to provide history or make decisions due to their critical condition, communication with family is essential for care planning.

Use CPT® code 99291 to report the first 30-74 minutes of critical care. For each additional block of 30 minutes beyond the initial 74 minutes, report CPT® add-on code +99292. It’s critical to note that critical care time less than 30 minutes is not reported using critical care codes. In such cases, the appropriate Evaluation and Management (E/M) code should be used instead.

Examples of Critical Care Time Reporting:

• 35 minutes of critical care: Report 99291
• 115 minutes of critical care: Report 99291, 99292 x 2 (representing two additional 30-minute blocks after the initial 74 minutes).

The critical care clock stops when separately reportable procedures or services are performed. Time spent performing these separately billed services, or activities not directly contributing to the treatment of the critical patient, cannot be included in critical care time. Therefore, meticulous documentation of time spent on critical care activities versus separately billable procedures is essential for accurate coding.

4. Thou Shalt Know the Key Elements

To appropriately report critical care codes 99291/99292, both the patient’s illness or injury and the treatment provided must meet the stringent critical care requirements. Beyond just time documentation, the clinical reassessments and overall documentation must robustly support the aggregated critical care time. This documentation should clearly articulate:

• Interval Assessments: A detailed description of all physician assessments of the patient’s condition throughout the critical care period. This should reflect the dynamic nature of critical care and how the patient’s status is continuously evaluated.
• Organ System Impairments: Identification and documentation of all impaired organ systems, based on all relevant data available to the physician, including symptoms, signs, and diagnostic findings (lab results, imaging, etc.). This demonstrates the complexity and severity of the patient’s condition.
• Rationale and Timing of Interventions: Clear explanation of the clinical reasoning behind each intervention and the timing of these interventions. This demonstrates the physician’s high-level decision-making in managing the critical illness.
• Patient’s Response to Treatment: Documentation of the patient’s response to the treatments provided. This reflects the effectiveness of the critical care interventions and the ongoing monitoring of the patient’s condition.

Comprehensive documentation encompassing these elements is crucial for justifying critical care coding and ensuring compliance with payer requirements.

5. Thou Shalt Not Report Critical Care in the ER with an E/M Code for a Medicare Patient by the Same Physician on the Same Calendar Day

CMS Transmittal 1548 specifically addresses the scenario of critical care provided in the Emergency Department. For Medicare patients, when critical care services are required upon arrival in the ED, only critical care codes (99291-99292) may be reported. An ED Evaluation and Management (E/M) code (99281-99285), when provided by the same physician (or physicians of the same specialty in the same group) to the same patient on the same calendar day, cannot be reported in addition to critical care codes.

This is a key distinction for Medicare. While CPT® guidelines do not explicitly prohibit reporting both an E/M service and critical care on the same day, CMS policy for the ED is very clear: it’s one or the other, not both, when provided by the same physician on the same day.

Example: A Medicare patient presents to the ED and initially receives a high-level ED workup (e.g., 99285). Later, during the same encounter, the patient’s condition deteriorates unexpectedly, requiring critical care services. Under CMS rules, the “same” ED physician can only report either the ED E/M service or the critical care service – not both. The physician must choose the service that best reflects the predominant level of care provided.

It is important to note that under Medicare rules, critical care can be provided on the same day as an inpatient or outpatient E/M service if the services are distinct and meet specific criteria (e.g., critical care provided later in the day after an initial office visit). However, in the ED setting, the same-day E/M and critical care limitation applies for Medicare.

While CMS has this specific rule, CPT® allows for separate reporting of both an E/M service and critical care service on the same day, without specifying the site of service or order of services. Therefore, it is crucial to check your state’s Medicaid policies and individual commercial payers’ medical policies to ensure correct reporting of critical care services and maintain compliance. Some payers, even commercial ones, may follow CMS guidelines or have similar restrictions. Certain payers might require modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to be appended to a same-day, non-critical care E/M service if both are indeed separately reportable according to their policies. Always verify payer-specific guidelines.

6. Thou Shalt Not Bundle

Both CPT® and CMS consider certain services to be inherently included (bundled) within critical care time when performed during the critical care period by the same physician(s) providing critical care. These bundled services should not be reported separately in addition to critical care codes.

CMS specifies that the relevant time frame for bundling encompasses the entire calendar day for which critical care is reported. This is broader than CPT®, which might imply bundling only during the period the patient is actively critically ill. Under CMS, if critical care is billed for any part of a calendar day, the bundling rules apply to the entire day.

The following services are bundled into critical care by both CPT® and CMS and should not be billed separately when critical care is reported for the same calendar day by the same physician:

• Interpretation of cardiac output measurements (93561, 93562)
• Pulse oximetry (94760, 94761, 94762)
• Chest X-rays, professional component (interpretation only) (71010, 71015, 71020)
• Blood gases analysis and data stored in computers (e.g., ECGs, blood pressures, hematologic data) (99090 – Note: 99090 is for physician review/interpretation of data transmitted from a device, not routine in-hospital data review)
• Gastric intubation (43752, 91105)
• Transcutaneous pacing (92953)
• Ventilator management (94002-94004, 94660, 94662)
• Vascular access procedures (36000, 36410, 36415, 36591, 36600) – These generally refer to simple venous/arterial access, not complex procedures.

Any services performed during the critical care period that are not explicitly listed above as bundled may be reported separately, provided they meet the criteria for separate reporting. Physicians are encouraged to document the time involved in performing separately reportable procedures, but remember that this time cannot be counted towards critical care time.

For further examples of ER billing and coding scenarios, you can consult resources like: http://emcrit.org/190-201/197-ed.billing.htm. Understanding bundling rules is crucial to avoid overcoding and ensure compliant billing practices.

7. Thou Shalt Remember to Code Everything Separately Allowed

While some services are bundled into critical care, it’s equally important to recognize and report services that are explicitly allowed to be billed separately. Remember, the critical care “clock stops” when performing these separately billable procedures, and the time spent on these procedures cannot be included in critical care time calculation.

Some common procedures that may be performed for a critically ill or injured patient and are typically reported separately from critical care (when medically necessary and appropriately documented) include:

• 92950 Cardiopulmonary resuscitation (CPR) (e.g., in cardiac arrest)
• 31500 Intubation, endotracheal, emergency procedure
• 36555 Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age
• 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older
• 36680 Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to vein
• 32551 Tube thoracostomy, includes water seal (e.g., for abscess, hemothorax, empyema), when performed as a separate procedure
• 33210 Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure)
• 93010 Electrocardiogram (ECG), routine ECG with at least 12 leads; interpretation and report only (professional component)

This is not an exhaustive list, and the specific circumstances of each patient encounter should guide coding decisions. Always ensure that separately reported procedures are medically necessary, appropriately documented, and distinct from the services already encompassed within critical care.

8. Thou Shalt Know the Appropriate Use of Modifier 25

CPT® guidelines do not inherently require modifier 25 when billing for critical care services and/or separately billable (non-bundled) procedures performed on the same day. However, CMS and many other commercial payers may require modifier 25 on the E/M service code when a significant, separately identifiable E/M service is performed on the same day as a procedure or another E/M service.

Specifically in the context of critical care, some payers may require modifier 25 to be appended to critical care codes (99291/99292) when a separately billable (non-bundled) procedure is also performed on the same day. This signifies that the critical care service was a “significant, separately identifiable service” that went beyond the typical pre- and post-procedure care associated with the separately billed procedure.

Example: If endotracheal intubation (31500) and cardiopulmonary resuscitation (CPR) (92950) are performed and critical care services (99291/99292) are also provided during the same patient encounter, some payers may require modifier 25 to be appended to the critical care code to indicate that the critical care was a significant and separately identifiable service, distinct from the procedures.

Always check your specific payers’ medical policies in your state to determine their requirements regarding modifier 25 use with critical care and separately billable procedures. Payer policies can vary, and compliance is essential for accurate claims processing and avoiding denials.

9. Thou Shalt Correctly Report CPR and Critical Care During Same Patient Encounter

CPT® and CMS both agree that cardiopulmonary resuscitation (CPR) (92950) and critical care (99291-99292) can be reported together for the same patient encounter, provided that the requirements for each service are independently met and clearly documented in the medical record.

CPR encompasses the immediate, life-saving interventions performed during cardiac arrest, such as chest compressions, ensuring adequate ventilation (e.g., bag-valve-mask), and related resuscitative efforts. CPT® does not specify a minimum time requirement for CPR to be reported and designates it as a separately reportable service that can be billed in addition to critical care, when both are appropriately provided.

Key Point: Time spent providing CPR cannot be counted towards the total critical care time. These are distinct services, and while they may occur concurrently or sequentially in a critical patient, the time accounting for each is separate.

Therefore, if a physician provides both CPR and critical care during an ED encounter, and both services are well-documented and meet the respective coding criteria, both codes (92950 and 99291/99292) can be reported. Accurate documentation is paramount to support the medical necessity and distinct nature of each service.

10. Thou Shalt Ensure Teaching Physician Criteria Is Properly Documented

When critical care is provided in a teaching setting, specific documentation guidelines must be followed to ensure proper billing under the teaching physician rules. Teaching physicians can leverage the resident physician’s documentation but must provide specific attestation to the critical care they personally provided.

Teaching physicians may refer to the resident’s documentation for details regarding patient history, physical findings, and medical assessments when documenting critical care. However, the teaching physician’s note must include a distinct statement about the total time they personally spent providing critical care. This statement must also include:

• Confirmation that the patient was critically ill when the teaching physician evaluated them.
• A clear explanation of why the patient was considered critically ill, specifying the critical condition(s).
• A description of the nature of the treatment and management personally provided by the teaching physician.

CMS provides the following vignette as an example of acceptable teaching physician documentation for critical care: “Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident’s documentation and I agree with the resident’s assessment and plan of care.”

Important Note: Time spent solely by the resident performing critical care activities in the absence of the teaching physician cannot be counted towards critical care time billed under the teaching physician’s provider number. Only time spent performing critical care activities by the resident and teaching physician together, or by the teaching physician alone, can be included in the teaching physician’s critical care time. Accurate and compliant documentation is essential for teaching physicians to appropriately bill for critical care services.

Bonus Tip: If There Is Food, Critical Care Isn’t Happening

While seemingly simplistic, this “bonus tip” provides a practical indicator. Critical care is generally no longer appropriate when a patient’s critical conditions have resolved or stabilized to the point where they are able to eat a regular meal and drink beverages normally. For example, when septic shock has resolved, acute respiratory failure is controlled, and other acute situations are well-managed, the need for critical care likely has passed. A patient sitting up, eating, and drinking is generally not in a critically deteriorating state.

Ultimately, strong and supportive documentation, coupled with clear medical necessity that demonstrates not just an acute diagnosis but also the need for emergent and critical interventions, is the cornerstone of accurate and compliant critical care coding in the emergency room. Adhering to these ten commandments will significantly improve your understanding and application of critical care coding principles.

Holly Cassano, CPC, has been certified for more than three years and has been involved in practice management, coding, auditing, teaching, and consulting for multiple specialties for the past 13 years. She served two terms as an AAPC local chapter officer and has written several articles for Justcoding.com and has a monthly column devoted to Fighting Fraud, with Advance for Health Information Professionals. She is the coder and physician educator for emergency room physicians at the Cleveland Clinic Florida. You can reach her at [email protected].