Facility Critical Care Coding: A Comprehensive Guide for Hospitals

Facility coding in healthcare settings, particularly within the emergency department (ED), operates under distinct principles compared to professional coding. Understanding these differences is crucial for accurate billing and compliance, especially when it comes to Facility Critical Care Coding. This guide, tailored for content creators at carcodescanner.store and healthcare professionals alike, delves into the intricacies of facility critical care coding, aiming to provide a superior, SEO-optimized resource for the English-speaking market.

Facility coding, unlike professional coding which focuses on physician services, is centered on the resources and intensity of care provided by the hospital facility. This distinction is paramount in areas like the ED, where rapid and resource-intensive interventions are common. The Centers for Medicare & Medicaid Services (CMS) established the Outpatient Prospective Payment System (OPPS) and Ambulatory Payment Classifications (APCs) to govern facility outpatient service payments, drawing a clear line from the physician-centric Diagnosis Related Groups (DRGs) used for inpatient services. It’s important to note that APCs are specific to hospitals and do not dictate physician payments under the Medicare Physician Fee Schedule.

Understanding Facility vs. Professional Coding

The fundamental difference lies in what each coding system measures. Professional coding evaluates the complexity of a provider’s work, including their cognitive effort and the procedures they perform. Facility coding, conversely, captures the hospital’s resource utilization – the nursing care, ancillary services, supplies, and equipment necessary for patient care. Consequently, directly translating codes from one system to the other is inappropriate and lacks a logical basis. Each system is designed to reflect different aspects of healthcare delivery.

Triage-Only Visits and Facility Coding

CMS has provided guidance on “triage-only” visits within the OPPS framework. Importantly, CMS does not dictate the staff type required to provide services. Hospitals are empowered to establish their own coding guidelines for visit levels, provided these guidelines logically link the intensity of hospital resources to specific HCPCS codes. Medical necessity and thorough documentation remain essential prerequisites for billing any visit code.

However, it’s crucial to distinguish between therapeutic and diagnostic services. CMS clarified in a 2012 Facility FAQ that outpatient therapeutic services and supplies, including visits, must be “incident to” a physician’s service and ordered by a physician or qualified practitioner. Standing orders for nurses alone do not meet this “incident to” requirement for therapeutic services. Diagnostic services, on the other hand, do not need to meet this “incident to” rule. This means diagnostic services can be coded even if a patient leaves before physician examination.

Hospital-Specific Guidelines for E&M Coding

Currently, there is no national standard for assigning Evaluation and Management (E&M) code levels for outpatient services in hospital clinics and emergency departments. CMS mandates that each hospital develop its own facility billing guidelines. These guidelines are expected to meet eleven criteria outlined in OPPS, as detailed in the CMS Final Rule (2009). Effective facility billing guidelines should:

Relate hospital service intensity to code levels reasonably.
Be clear and unambiguous to ensure accurate payments.
Require only clinically necessary documentation for patient care.
Prevent upcoding or gaming of the system.

ACEP Facility Coding Model

The American College of Emergency Physicians (ACEP) has developed a facility coding model that aligns with OPPS principles, offering a potential framework for hospitals. These guidelines are presented as one possible approach, and facilities should assess their suitability and adapt them to their specific institutional context. Many institutions find customization beneficial to address their unique needs.

Instructions for Using the ACEP Facility Coding Model

The ACEP model simplifies visit level assignment in the ED using a three-column format.

Facility Codes & APC Levels (Left Column): Lists the facility codes (like 99281-99285 and 99291 for critical care) and corresponding APC levels.
Possible Interventions (Middle Column): This is the key determinant for code assignment. It lists interventions performed by nursing and ancillary ED staff. These interventions reflect the intensity of facility resources used. Procedure examples are included as proxies for service intensity, not as substitutes for separately billable procedures.
Potential Symptoms/Examples (Right Column): This column serves as an aid for coders by providing examples of symptoms that typically correlate with the interventions in the middle column. Crucially, this column is not used to determine the appropriate facility code. Code assignment is solely based on the “Possible Interventions.”

To use these guidelines:

Identify all “Possible Interventions” performed by nursing and ancillary staff for a patient encounter.
Locate these interventions within the middle column of the ACEP guidelines.
Determine the highest facility code level associated with any of the identified interventions.
Assign that facility code level. The presence of multiple interventions at the same level, or interventions from lower levels, does not change the assigned code level. The highest level with at least one matching intervention dictates the code.

The phrase “Could include interventions from previous (lower) levels, plus any of:” in the “Possible Interventions” column means that higher levels inherently encompass interventions from lower levels. For example, if an intervention qualifies for a 99283 level, and lower-level interventions (99281, 99282) are also present, the assigned code remains 99283.

Examples of Facility Code Assignment

Example #1: Complex Pelvic Pain

A 48-year-old woman with a history of myocardial infarction and atrial fibrillation presents to the ED with pelvic pain. ED staff interventions include:

Initial nursing assessment
Stool hemoccult and urine dipstick tests
Saline lock insertion and blood draw for lab tests
Foley catheter insertion for urine specimen
Pelvic ultrasound preparation and transport with cardiac monitoring
Complex discharge instructions

Using the ACEP guidelines:

We look for “Pelvic Pain” in the “Potential Symptoms/Examples” column but find “Abdominal Pain” listed at levels 99284 and 99285.
Reviewing “Possible Interventions” for 99285, we find:
- Monitoring vital signs during in-hospital transport and testing.
- Discussion of Discharge Instructions “Complex.”
Since interventions matching the 99285 level are present, the appropriate facility code is 99285 (APC 616).

Example #2: Acute Cystitis

A 66-year-old healthy woman presents to the ED with fever, dysuria, and urinary frequency. ED staff interventions include:

Nursing assessment
Urine dipstick test
“In and out” Foley catheterization for urine specimen
Administration of oral Pyridium and Sulfamethoxazole/Trimethoprim in the ED
Moderate complexity discharge instructions

Using the ACEP guidelines:

Relevant “Potential Symptoms/Examples” include “Medical conditions requiring prescription drug management” and “Fever which responds to antipyretics,” aligning with level 99283.
Reviewing “Possible Interventions” for 99283, we find:
- Prescription medications administered PO.
- Foley catheters; In & Out caths.
- Discussion of discharge instructions (Moderate Complexity).
No interventions reach the 99284 or 99285 levels. Therefore, the appropriate facility code is 99283 (APC 614).

Facility Critical Care Coding (99291 – APC 617)

Facility critical care coding, specifically using code 99291, follows the same logic as E&M codes 99281-99285 within the ACEP framework. A crucial requirement for facility billing of critical care is a minimum of 30 minutes of critical care time.

Key indicators of critical care interventions include the administration and monitoring of intravenous vasoactive medications such as adenosine, dopamine, labetolol, metoprolol, nitroglycerin, norepinephrine, and sodium nitroprusside.

Example: Status Epilepticus and Critical Care

A 68-year-old man is brought to the ED by EMS in status epilepticus. ED staff interventions include:

Multiple diagnostic tests
2 mg Ativan IV followed by IV Dilantin infusion
IV sodium nitroprusside for hypertension management
CT scan revealing intracerebral hemorrhage
Transfer to another hospital for neurosurgical care
Documented 45 minutes of critical care time

Using the ACEP guidelines for critical care:

Relevant “Potential Symptoms/Examples” include “Status-Asthmaticus, Epilepticus” and “Cerebral Hemorrhage of any type.”
Reviewing “Possible Interventions” for critical care, we find:
- Multiple parenteral medications requiring constant monitoring (Dilantin and sodium nitroprusside IV drips).
With documented critical care time exceeding 30 minutes and a qualifying intervention present, the appropriate facility code is 99291 (APC 617).

Critical care coding (99291) is applied when the facility provides interventions for patients experiencing critical illness or injury. According to CPT guidelines, critical care involves “decision-making of high complexity to assess, manipulate, and support impairments of one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.” This encompasses managing conditions like central nervous system failure, shock, respiratory failure, and postoperative complications. The time counted towards critical care is the time spent by physicians and/or hospital staff in active, face-to-face critical care. If multiple staff members are simultaneously involved, the time is counted only once.

For critical care exceeding 74 minutes, and in subsequent 30-minute increments beyond the initial 74 minutes, CPT code 99292 may be reported. However, it’s important to note that Medicare typically packages code 99292 into 99291 for payment purposes, although reporting remains appropriate for capturing the full scope of services.

In designated trauma centers, an additional code, G0390 (APC 618 – Critical Care with Trauma Team Activation), may be reported alongside 99291 when a trauma team is activated and specific trauma activation criteria are met.

Definitions for Discharge Instructions

The ACEP guidelines also define levels of discharge instructions, which factor into E&M code assignment:

Straightforward: For self-limited conditions requiring no medication or home treatment. Instructions include signs of wound infection and when to return to the ED.
Simple: Involves over-the-counter medications or simple treatments like dressing changes. Patients easily understand instructions.
Moderate: Includes head injury instructions, crutch training, prescription medications with side effect review, and limitations on activity. Patients generally understand instructions with minor questions.
Complex: Involves multiple prescription medications or home therapies, teaching for conditions like diabetes, seizures, or asthma in challenging patients. Patients may struggle to understand and require significant support for compliance.

Disclaimer

It is essential to recognize that the ACEP ED Facility Level Coding Guidelines are for informational purposes only. While developed from knowledgeable sources, ACEP does not guarantee complete accuracy or completeness. ACEP disclaims liability for damages arising from the use of or reliance on these guidelines. These guidelines are not a definitive reference for CMS OPPS coding, which is case-specific, evolving, and ultimately determined by CMS payment policies. For payment-related questions, direct inquiries to CMS.

	Facility Charge Assignment
Level	Possible Interventions¹	Potential Symptoms/Examples which support the Interventions
ICPT 99281 Type A: APC 609 Type B: APC 626 HCPCS: G0380	Initial Assessment No medication or treatments Rx refill only, asymptomatic Note for Work or School Wound recheck Booster or follow up immunization, no acute injury Dressing changes (uncomplicated) Suture removal (uncomplicated) Discussion of Discharge Instructions (Straightforward)	Insect bite (uncomplicated) Read Tb test
IICPT 99282 Type A: APC 613 Type B: APC 627 HCPCS: G0381	Could include interventions from previous levels, plus any of: Tests by ED Staff (Urine dip, stool hemoccult, Accucheck or Dextrostix) Visual Acuity (Snellen) Obtain clean catch urine Apply ace wrap or sling Prep or assist w/ procedures such as: minor laceration repair, I&D of simple abscess, etc. Discussion of Discharge Instructions (Simple)	Localized skin rash, lesion, sunburn Minor viral infection Eye discharge- painless Ear Pain Urinary frequency without fever Simple trauma (with no X-rays)
IIICPT 99283 Type A: APC 614 Type B: APC 628 HCPCS: G0382	Could include interventions from previous levels, plus any of: Receipt of EMS/Ambulance patient Heparin/saline lock¹ Nebulizer treatment Preparation for lab tests described in CPT (80048-87999 codes) Preparation for EKG Preparation for plain X-rays of only 1 area (hand, shoulder, pelvis, etc.) Prescription medications administered PO Foley catheters; In & Out caths C-Spine precautions Fluorescein stain Emesis/ Incontinence care Prep or assist w/procedures such as: joint aspiration/injection, simple fracture care etc. Mental Health-anxious, simple treatment Routine psych medical clearance Limited social worker intervention Post mortem care Direct Admit via ED Discussion of Discharge Instructions (Moderate Complexity)	Minor trauma (with potential complicating factors) Medical conditions requiring prescription drug management Fever which responds to antipyretics Headache – Hx of, no serial exam Head injury- without neurologic symptoms Eye pain Mild dyspnea -not requiring oxygen
IVCPT 99284 Type A: APC 615 Type B: APC 629 HCPCS: G0383	Could include interventions from previous levels, plus any of: Preparation for 2 diagnostic tests²: (Labs, EKG, X-ray) Prep for plain X-ray (multiple body areas): C-spine & foot, shoulder & pelvis Prep for special imaging study (CT, MRI, Ultrasound,VQ scans) Cardiac Monitoring ² Nebulizer treatments Port-a-cath venous access Administration and Monitoring of infusions or parenteral medications (IV, IM, IO, SC) NG/PEG Tube Placement/Replacement Multiple reassessments Prep or assist w/procedures such as: eye irrigation with Morgan lens, bladder irrigation with 3-way foley, pelvic exam, etc. Sexual Assault Exam w/ out specimen collection Psychotic patient; not suicidal Discussion of Discharge Instructions (Complex)	Blunt/ penetrating trauma- with limited diagnostic testing Headache with nausea/ vomiting Dehydration requiring treatment Vomiting requiring treatment Dyspnea requiring oxygen Respiratory illness relieved with (2) nebulizer treatments Chest Pain–with limited diagnostic testing Abdominal Pain – with limited diagnostic testing Non-menstrual vaginal bleeding Neurologic symptoms – with limited diagnostic testing
VCPT 99285 Type A: APC 616 Type B: APC 630 HCPCS: G0384	Could include interventions from previous levels, plus any of: Requires frequent monitoring of multiple vital signs (ie. 02 sat, BP, cardiac rhythm, respiratory rate) Preparation for ≥ 3 diagnostic tests²: (Labs, EKG, X-ray) Prep for special imaging study (CT, MRI, Ultrasound, VQ scan) combined with multiple tests or parenteral medication or oral or IV contrast. Administration of Blood Transfusion/Blood Products Oxygen via face mask or NRB Multiple Nebulizer Treatments: (3) or more (if nebulizer is continuous, each 20 minute period is considered treatment) Moderate Sedation Prep or assist with procedures such as: central line insertion, gastric lavage, LP, paracentesis,etc. Cooling or heating blanket Extended Social Worker intervention Sexual Assault Exam w/ specimen collection by ED staff Coordination of hospital admission/ transfer or change in living situation or site Physical/Chemical Restraints; Suicide Watch Critical Care less than 30 minutes	Blunt/ penetrating trauma requiring multiple diagnostic tests Systemic multi-system medical emergency requiring multiple diagnostics Severe infections requiring IV/IM antibiotics Uncontrolled DM Severe burns Hypothermia New-onset altered mental status Headache (severe): CT and/or LP Chest Pain–multiple diagnostic tests/treatments Respiratory illness–relieved by (3) or more nebulizer treatments Abdominal Pain–multiple diagnostic tests/treatments Major musculoskeletal injury Acute peripheral vascular compromise of extremities Neurologic symptoms – multiple diagnostic tests/treatments Toxic ingestions Mental health problem – suicidal/ homicidal
Critical Care – Critical Care can be coded based upon either the provision of any of the listed possible interventions or by satisfying the Critical Care definition. A minimum of 30 minutes of care must be provided. Critical Care Involves decision-making of high complexity to assess, manipulate, and support impairments of “one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” This includes, but is not limited to, “the treatment or prevention of further deterioration of central nervous system failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, post-operative complications or overwhelming infection.” Under OPPS, the time that can be reported as Critical Care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once.
	Possible Interventions	Potential Symptoms/Examples which support the Interventions
CPT 99291 Type A: APC 617	Could include interventions from previous levels, plus any or all of: Multiple parenteral medications requiring constant monitoring Provision of any of the following: Major Trauma care/ multiple surgical consultants Chest tube insertion Major burn care Treatment of active chest pain in ACS Administration of IV vasoactive meds (see guidelines) CPR Defibrillation/ Cardioversion Pericardiocentesis Administration of ACLS Drugs in cardiac arrest Therapeutic hypothermia Bi-PAP/ CPAP Endotracheal intubation Cricothyrotomy Ventilator management Arterial line placement Control of major hemorrhage Pacemaker insertion through a Central Line Delivery of baby	Multiple Trauma; Head Injury with loss of consciousness Burns threatening to life or limb Coma of all etiologies (except hypoglycemic) Shock of all types: septic, cardiogenic, spinal, hypovolemic, anaphylactic Drug Overdose impairing vital functions Life-threatening hyper/ hypo-thermia Thyroid Storm or Addisonian Crisis Cerebral hemorrhage of any type New-onset paralysis Non-hemorrhagic strokes with vital function impairment Status epilepticus Acute Myocardial Infarction Cardiac Arrythmia requiring emergency treatment Aortic Dissection Cardiac Tamponade Aneurysm; thoracic or abdominal — leaking or ruptured Tension Pneumothorax Acute respiratory failure, pulmonary edema, status asthmaticus Pulmonary Embolus Embolus of fat or amniotic fluid Acute renal failure Acute hepatic failure Diabetic Ketoacidosis Lactic Acidosis DIC or other bleeding diatheses – hemophilia, ITP, TTP, leukemia, aplastic anemia Major Envenomation by poisonous reptiles
CPT 99292	As above in additional 30 minute increments. Record the TOTAL critical care time. The first 30-74 minutes equal code 99291. If used, additional 30 minute increments (beyond the first 74 minutes) are coded 99292. Medicare does not pay for code 99292 because it is considered packaged into 99291; however the services should be reported as appropriate.
Critical Care with Trauma Team Activation APC 618 G0390	In addition to 99291, designated trauma centers may report the Trauma Team Activation code G0390 when a trauma team was activated and all other trauma activation criteria are met.
Copyright © 2011 American College of Emergency Physicians

Footnote 1: Hospital outpatient therapeutic services and supplies (including visits) must be furnished incident to a physician’s service and under the order of a physician or other qualified practitioner. Services provided by a nurse in response to a standing order do not satisfy this requirement. Since Diagnostic tests do not have to be performed incident to a physician service, they may be coded even if the patient were to leave without being seen by the physician.

Footnote 2: As of 2021, CPT has clarified that a test is defined as a service that has a separate CPT code. Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test. The differentiation between single or multiple unique tests is defined in accordance with the CPT code set.