Max Reimbursements

No Comments
Critical Care: How to stop leaving money on the table

Critical care, particularly in emergency medicine, is an underused code. And, while it isn’t an ideal system, you’ve got to  bill for services provided using the rules provided. Improving your reimbursement by documenting better is a whole lot easier than doing so by seeing more patients.
Claiming critical care is a 3-part process: 
1. Your patient needs to meet the critical care definition
2. You need to provide critical care services and;
3. You need to document the estimate of the time spent providing the service.

The CPT definition for critical care services is as follows:

“Critical illness or injury ‘acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration’ in the patient’s condition.” CC must be medically necessary (i.e. qualifies under the new CC definition); otherwise, it should be coded and billed under the appropriate E/M. CC services involve high complexity decision making to treat single or multiple vital organ failure. For example:
Central nervous system
Circulatory failure
Renal, hepatic, metabolic, respiratory

Of special interest is the use of critical care and E/M levels of service codes. CMS states hospital emergency department E/M levels of service are not payable for the same calendar date as critical care services when provided by the same physician for the same patient. In other words, when a patient requires 30 minutes or more of CC services upon presentation or any time during the ED encounter, only the CC code may be coded and billed on behalf of the emergency physician.  Although other services, such as separately billable procedures, (i.e. CPR, central line placement and endotracheal intubation) can be billed for, the time spent cannot be included in the CC time calculation. Once critical care time is claimed, E/M levels of service (99281, 99282, 99283, 99284 and 99285) cannot be used.  The good news is that critical care codes (99291, for the first 30 minutes and 99292) compensate us far better than even a level 5 (99285) ever would.


Certain activities cannot be included in your critical care time calculation/estimate.  Such activities include time spent performing separately billable procedures and time spent with certain family interactions.  Conversations with the patient’s family obtaining history and exploring treatment options may be included toward CC time, as the family is used as the patient’s proxy. 

Examples of reportable time for family discussions include: 
-Patient is unable to provide history or make treatment decisions
-There is a strong necessity for family discussion to determine medically necessary treatment options
-Medical record documentation supports necessity of discussion (no other source available, rapid deterioration)
Note: Time spent updating or giving reports to the family is considered routine and non-reportable as CC time. 

Remember the CC documentation basics: The physician must make a statement of the amount of time that he/she spent providing services to the patient and the rest of their documentation should support the critical nature of the patient’s presentation/illness and the care provided. Critical care time includes: attending to the patient, reviewing labs, old records, family inquiry/discussion, consult discussion time with other physicians, giving orders and documenting the patient encounter. Separately billable procedures (i.e. intubation, central lines, etc.) should be excluded from total reported CC time.  Also, it is critical to remember that the time spent must be exclusive to that particular patient.  Thus, spending time multitasking cannot be included.  In example, if you work an 8 hour shift and you claim 4 hours of critical care time, you are stating that for half of your shift, you only took care of your critical care patient.


Stay tuned for possible updates to the critical care language in 2009.

Sharon L. Nicka, RN, CPC, is the CEO and president of Nicka & Associates, Inc.,    


Leave A Reply