Your Critical Care Reimbursement: Learn how to succeed

No Comments

Don’t miss out for failing to properly document.

What you document makes a difference. Astutely charting the detail of your service can allow your coders to distinguish between a level 5 and level 4 chart resulting in a revenue of $56.52. Properly distinguishing between “complex” and “simple” abscess drainage provides an increased reimbursement of $84.60. Specifying between a “post-arthroplasty” and “native” hip reduction results in a billing difference of $225.72. These figures are based on the 2018 Medicare Physician Fee Schedule.(1) None of these values can be realized without the appropriate attention to detail in your charting.


Critical Care billing (30 to 74 minutes) generates $226.80 for each applicable patient encounter. This figure is based on the 2018 Medicare Physician Fee / RVU Conversion Factor, 1 RVU = $36 (precise amount, geographic specific). If you overlook charting the appropriate Critical Care time, $50.76 is left unrealized (as compared to the reimbursement generated through a level 5 (99281 chart)). This amount is even higher when being paid through some private insurers. Your ability to chart properly is the key. Your documentation has a tremendous impact on the amount that is received for your services.

Many encounters involving the provision of Critical Care never reach their full reimbursement potential. Information shortfalls provided by clinicians results in coder building shortfalls. Medical billing coders can only code with the information available to them in a chart. The solution: learn what it takes to chart optimally.

Critical Care Time Defined

As defined by AMA CPT 2018, a critical illness is an “illness or injury [which]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.”(2) 


Before you consider billing for Critical Care, make sure the encounter qualifies with a critical illness. To illustrate:  An 18-year-old male presents with a moderate thigh cellulitis and localized thigh abscess. Presuming he has no known medical problems and is otherwise well-appearing, this case will likely not qualify for Critical Care Time. You may perform an incision & drainage, administer IV antibiotics, consult the primary physician and ultimately admit this patient. However, if the patient has no immediate “high probability of imminent or life-threatening deterioration,” Critical Care services do not apply.

Conversely, consider this hypothetical case involving a 46-year-old diabetic female who presents with a thigh abscess: If this patient arrives with a heart rate of 120, blood pressure of 94/50, temperature of 101.4, and blood sugar of 460, this encounter will likely involve Critical Care services. The differential diagnosis in this case includes sepsis, bacteremia, dehydration, electrolyte imbalances and DKA.

Your work-up will likely include labs, blood cultures, and ABG analysis. Your interventions will likely include IV crystalloids, IV antibiotics and administration of insulin. Your Critical Care service may involve consultation with infectious disease, endocrinology, and/or general surgery. This patient’s presentation has definite potential for life-threatening deterioration.

Here is another Critical Care Time example.  A 52-year-old-male presents with a scalp hematoma, confusion, left sided rib bruising and a history of alcohol use after having an unwitnessed fall.  In this case, your differential diagnosis and work-up will likely revolve around the evaluation of the patient’s acute head injury, exclusion of pneumothorax, consideration of overdose and management of his alcohol intoxication. A “high probability of imminent or life-threatening deterioration in the patient’s condition” exists here.


All That It Is Critical Care Time

Primary services that count towards Critical Care include the following (as outlined by AMA CPT 2018):

  • Provision of care towards a critically ill or injured patient
  • Discussion of the case with the family or surrogate decision makers (provided the conversation bears directly on the management of the patient)
  • Review of records and computer information data interpretation (i.e. EKGs, BPs and Lab data)
  • Pulse ox, Chest X-ray, ABG interpretations and Ventilator management
  • Discussion with the primary physician and consultants (as long as it bears directly on the management of the patient)
  • Chart documentation

Additional Noteworthy Critical Care Activities

While the following may be infrequent interventions, these services also contribute to your Critical Care Time.

  • Vascular access procedures (peripheral IV when nursing unable to obtain, though not other lines)
  • Blood draw (if staff unable to obtain)
  • OGT/NGT placement (if staff unable to place)
  • Cardiac output interpretation
  • Transcutaneous pacing

All of these activities contribute to your aggregate time. In a busy Emergency Room, this time can add up quickly. Keep in mind the Critical Care time you provide. Also, be sure to note these interventions in your documentation.

Critical Care Time: All That It Is Not

Not every service you provide counts toward Critical Care time. Your time spent with “separately reported billable procedures” such as the following below cannot be counted towards Critical Care time.

  • EKG Interpretation • Central venous catheter
  • Intubation • Interosseous lines
  • CPR • Procedural sedation
  • Chest tubes • Wound care/Fracture care

Also, “non critical” conversations cannot be applied towards Critical Care. While reminiscing with former neighbors from years ago may improve your patient satisfaction scores, such activity certainly resides outside Critical Care time. Lastly, your documentation must specifically include an exclusionary statement that indicates these procedures were not counted in your Critical Care time.

Examples of conversations that do count toward Critical Care: discussing ventilator settings with the pulmonologist, blood pressure management with the cardiologist, and/or antibiotic selection with the infectious disease specialist. Such conversations bear “directly on the management of the patient.”

What Your Documentation Should Look Like

“I spent 30 minutes of critical care time with this patient. This does not include time spent on separately reported billable procedures.”

When appropriate, this is the marquee statement in Critical Care. Thirty minutes is the threshold at which Critical Care time can be specifically billed. Additional important service times occur at 75 and 105 minutes (and every 30 minutes beyond this).

Your Success Does Not Hinge on Your Diagnosis

Whether you diagnosis ends up being Aortic Dissection or Unspecified Chest Pain, a complex case may still qualify for Critical Care time. The complexity of a case —potential for “high probability of imminent or life-threatening deterioration” — and time you spend in Critical Care activities are the keys. It is all about the provision of care you provide to a critical ill (or potentially critically ill) patient – regardless of your final diagnosis. This is the reason your documentation detailing the complexity of your workup is so important.

Stand Up to the Challenge Quiz

Apply what you have learned and put your knowledge to the test. Review these three questions and check your answers below.

1. Which of the following DOES NOT count directly toward the provision of critical care time?

A. Pulse oximeter interpretation

B. Chest X-ray interpretation

C. ABG interpretation 

D. Ventilator management

E. Cardioversion


2. True or False? “The time you spend performing CPR on a patient counts toward Critical Care time.”


3. Which one of the following DOES NOT count towards Critical Care time?

A. Review of records and computer data interpretation

B. Discussion with the family / surrogate decision maker who directly bears on the patient’s management

C. Discussion with the primary physician and consultants about the patient’s care.

D. Intubation of the patient

E. Charting the patient’s encounter



1. E. Cardioversion does not count directly toward Critical Care time.

When you think of Critical Care time, “all things respiratory” should come to mind. Pulse ox, Chest X-ray, ABG interpretation as well as Ventilator management time – all of these count toward critical care. While cardioversion cannot be applied to Critical Care time, it is still important to document whenever it is performed. Elective cardioversion is a “separately reported billable procedure” (AMA CPT 92960) which is reimbursed at 3.14 RVUs.

2. False. The time you spend during CPR and the associated resuscitation efforts during this period cannot be applied toward Critical Care time. So, even if you spend 40 minutes caring for a patient while CPR is being performed, Critical Care time does not apply. Nevertheless, properly documented CPR, whether it is performed for four or 40 minutes, is a highly valued procedure with significant associated reimbursement. (CPR RVU = 5.34). Be sure to document any and all CPR you perform and/or supervise.

3. D. Intubation is considered a separately reported billable procedure and therefore does not count toward Critical Care time. All the other answers apply and should be documented. In regard to your time spent with charting, this can be applied towards Critical Care time. Your documentation is important. It facilitates the care of the patient via conveying crucial information to the primary physician and consultants.

3 Pearls for Successful Reimbursement

  • Critical Care revolves around patient context, your activities, and aggregate time of care. => It does not depend on your final diagnosis.
  • When managing complicated respiratory, think Critical Care. => Pulse ox, Chest X-ray and ABG interpretations as well as Ventilator management all count toward your time.
  • Your documentation really is a factor. => Your time spent with charting can be applied to Critical Care.

In the next issue of EP Monthly, the conclusion of this series will address the subtle nuances in Critical Care time. You’ll discover how these can have a big impact on your reimbursement. Empower yourself, and learn what it takes. Your best results are soon to come – you can succeed in optimizing the return for the care you provide.


  1. 2018 National Physician Fee Schedule Relative Value File, GPCI18, National Physician Fee Schedule Relative Value File Calendar Year 2018, MCR-MUE-Practitioner Services. Published by CMS. Effective: April 1, 2018.
  2. AMA Current Procedural Terminology (CPT) 2018 Professional Edition. 4th ed. Revised 2017: 23-25.


Dan Magdziarz, DO, is an attending ED physician practicing at Palos Hospital. His teaching, quality and reimbursement endeavors seek to promote excellence in Emergency Medicine. Share your interests and comments:; EDPMA: QCDC.

Leave A Reply