Emergency Department (ED) physicians frequently encounter scenarios requiring critical care, yet accurately coding for these services can be complex. Understanding Critical Care Coding In The Ed is crucial for appropriate reimbursement and reflecting the intensity of care provided. This article breaks down the key components of critical care coding, ensuring you’re equipped to document and bill effectively for your critical patients in the emergency setting.
Defining Critical Care in the Emergency Department
The Centers for Medicare and Medicaid Services (CMS) defines critical care as care delivered to patients with illnesses or injuries that acutely impair one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration. Furthermore, critical care necessitates frequent personal assessment and manipulation by the physician to prevent or manage this deterioration.
While conditions like cardiac arrest or major trauma clearly fall under critical care, numerous other ED encounters also qualify. Table 1, adapted from the American College of Emergency Physicians (ACEP) guidelines, highlights conditions and interventions frequently associated with critical care billing.
Table 1: Conditions and Interventions Often Justifying Critical Care Billing
| CONDITIONS Frequently Qualifying for Critical Care | INTERVENTIONS Often Associated with Critical Care Billing |
|---|---|
| Acute coronary syndrome with active chest pain | Arterial line placement |
| Acute hepatic failure | Major burn care |
| Acute renal failure | Cardiopulmonary resuscitation (CPR) |
| Acute respiratory failure | Chest tube insertion |
| Adrenal crisis | Cricothyrotomy |
| Aortic dissection | Defibrillation/Cardioversion |
| Bleeding diatheses (aplastic anemia, DIC, hemophilia, ITP, leukemia, TTP) | Delivery of baby |
| Burns threatening to life or limb | Emergent blood transfusions |
| Cardiac dysrhythmia requiring emergent treatment | Endotracheal intubation |
| Cardiac tamponade | Major hemorrhage control |
| Coma (most etiologies, excluding simple hypoglycemic coma) | Intravenous pacemaker insertion |
| Diabetic ketoacidosis or non-ketotic hyperosmolar syndrome | Invasive rewarming |
| Drug overdose | Non-invasive positive pressure ventilation (BiPAP or CPAP) |
| Ectopic pregnancy with hemorrhage | Pericardiocentesis |
| Embolus of fat or amniotic fluid | Therapeutic hypothermia |
| Envenomation | Trauma care requiring multiple surgical interventions or consultants |
| Gastrointestinal bleeding | Ventilator management |
| Head injury with loss of consciousness | Parenteral medications necessitating continuous monitoring, such as: – ACLS medications during cardiac arrest – Insulin infusions – Medications for heart rate/rhythm control – Naloxone infusions – Vasoactive medications |
| Hyperkalemia | |
| Hyper- or hypothermia | |
| Hypertensive emergency | |
| Ischemia of limb, bowel, or retina | |
| Lactic acidosis | |
| Multiple trauma | |
| New onset paralysis | |
| Perforated abdominal viscus | |
| Pulmonary embolism | |
| Ruptured aneurysm | |
| Shock (septic, cardiogenic, spinal, hypovolemic, anaphylactic) | |
| Stroke, hemorrhagic or ischemic | |
| Status epilepticus | |
| Tension pneumothorax | |
| Thyroid storm |
© 2011-2016, American College of Emergency Physicians. Adapted with permission.
Time as the Core of Critical Care Coding
Critical care billing hinges on time spent providing direct and indirect patient care. This contrasts with standard Evaluation and Management (E/M) coding. To bill critical care, a minimum of 30 minutes of critical care time must be dedicated to the patient on a given date.
Three primary Current Procedural Terminology (CPT) codes are used for critical care coding:
Table 2: Critical Care CPT Codes
| CODE | SERVICE Description |
|---|---|
| 99291 | Reported for the first 30-74 minutes of critical care on a single date. Critical care less than 30 minutes is billed using appropriate E/M codes. |
| 99292 | Used in conjunction with 99291 for each additional 30 minutes beyond the initial 74 minutes. |
| G0390 | Added to 99291 for Trauma Team Activation when specific criteria are met at designated trauma centers. |
Both direct patient care (e.g., physical examination, procedures) and indirect patient care activities contribute to critical care time. This includes time spent:
- Evaluating the patient
- Communicating with EMS and family
- Interpreting diagnostic studies (labs, imaging)
- Consulting with specialists or admitting teams
- Reviewing patient data and charts
- Documenting the encounter
- Performing procedures bundled into critical care
Crucially, time spent on separately billable procedures cannot be included in critical care time.
Table 3: Bundled vs. Separately Billed Procedures in Critical Care
| Procedures BUNDLED into Critical Care Time | Procedures Billed SEPARATELY |
|---|---|
| Interpretation of cardiac output, chest x-rays, pulse oximetry, blood gases, computer-stored data | Endotracheal intubation |
| Gastric intubation (e.g., nasogastric tube insertion) | Central venous access |
| Temporary transcutaneous pacing | Intraosseous line placement |
| Ventilator management | Transvenous pacing |
| Blood draws for specimen collection | Chest tube insertion |
| Peripheral intravenous access | Cardiopulmonary resuscitation (CPR) |
| Wound repair (simple) | |
| Electrocardiogram (ECG) interpretation | |
| Electrical cardioversion |
While precise timing isn’t required, accurate estimation and documentation of total critical care time are essential for proper billing. Key points to remember about critical care time:
- Additive: Time spent throughout the encounter accumulates towards the total critical care time.
- Once per day: Critical care time can only be billed once per patient, per day, by the same physician or group.
- Non-continuous: Critical care time doesn’t need to be consecutive; periods of critical care throughout the ED stay are added together.
- Attending physician involvement: Critical care billing necessitates direct involvement and documentation by an attending physician. Resident or mid-level provider time alone, without attending physician participation and attestation, is not reimbursable as critical care.
Image alt text: Kenneth Dodd, MD, Emergency Medicine and Internal Medicine Physician, author on critical care coding.
Essential Elements of Critical Care Documentation
Thorough documentation is paramount to justify critical care billing. Your chart should clearly articulate:
- The patient’s critical illness: Detail how the patient met CMS criteria for critical care due to organ system impairment and high risk of deterioration.
- Interventions provided: Specifically describe all critical care interventions performed.
- Cumulative critical care time: Document the total time spent on both direct and indirect critical care activities.
Consider incorporating these elements into your critical care documentation:
- Severity of illness and decompensation risk: Clearly state the severity and potential for deterioration.
- Vital signs and trends: Document abnormal vital signs (hypotension, hypoxia, etc.) and their changes in response to interventions.
- Diagnostic test interpretation: Record tests performed and your interpretation of results, linking them to the critical condition.
- Treatments: Detail all treatments administered, such as oxygen, IV fluids, medications, blood products, and wound care, and their critical impact.
- Procedures: Document all procedures performed, noting those bundled into critical care and any separately billable procedures.
- Re-assessments: Document frequent re-evaluations of patient status and responses to therapy.
- Communication: Record conversations with EMS, patient, family, consultants, and admitting teams, highlighting how these contributed to critical care management.
- Chart review findings: Note any relevant information gleaned from chart review and its impact on critical care decisions.
Remember that critical care documentation differs from standard E/M coding requirements. A chart billed for critical care will not have a separate E/M level assigned, as these coding systems are mutually exclusive. However, if critical care criteria are not met (or if the time threshold of 30 minutes isn’t reached), the encounter will be billed based on standard E/M codes. In cases of uncertainty, document elements supporting both critical care and E/M coding guidelines.
Case Re-evaluation: STEMI Patient in the ED
Consider the initial case: a patient with a STEMI rapidly transferred to the cardiac catheterization lab. While the patient met the clinical criteria for critical care (organ system dysfunction and high decompensation risk), if the total documented critical care time was less than 30 minutes, critical care billing is not appropriate. In this scenario, the encounter would be correctly billed at a lower level E/M code, such as Level 3 (99283), as mentioned in the original example. Therefore, always ensure both clinical criteria and the 30-minute time threshold are met for accurate critical care coding in the ED.
Optimizing Your Critical Care Coding Workflow
- Recognize critical care opportunities: ED physicians routinely provide critical care without always recognizing its billable nature. Reflect on your practice to identify missed critical care billing opportunities.
- Focus on medical decision-making in documentation: For critical care, emphasize documenting the severity of illness, interventions, and time spent. Detailed history and physical exam elements required for standard E/M coding are less critical in properly documented critical care encounters.
- Utilize templates or macros: Employing templates or macros can streamline critical care documentation, ensuring all necessary elements are captured efficiently and consistently.
By mastering critical care coding in the ED, you can ensure accurate reimbursement for the vital, life-saving care you provide to your most critically ill patients.
Ted Fan, MD
