03/25/2020 – Critical care billing tips

Critical care billing tips

Question: We are being asked to provide critical care on COVID-19 patients. Is there any guidance you can offer as far as documentation requirements?

Answer: Yes, please see the quick tips below for guidance.

Codes

  • Under 30 minutes, appropriate E & M code
  • 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
  • 99292 each additional 30 minutes (List separately in addition to code for primary service)

Definition

  • As per the CPT® guidelines, critical care (CC) is defined as the direct delivery by a physician of medical care for a critically ill or injured patient. A critical 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.”

Time based codes

  • Time must be documented in patients record and includes work directly related to the patients care, such as evaluating, providing and managing the care.
  • Time spent in activities that do not directly contribute to the treatment of the patient may not be reported as critical care, even if they are performed in the critical care unit e.g., review of literature, teaching sessions.

Services included in critical care

  • the interpretation of cardiac output measurements
  • chest X rays
  • pulse oximetry
  • blood gases, and collection and interpretation of physiologic data (e.g., ECGs, blood pressures, hematologic data).
  • gastric intubation
  • temporary transcutaneous pacing
  • ventilatory management
  • vascular access procedures

Documentation

The chart must provide adequate justification for why a patient meets CMS criteria for critical care billing. To do this, explain the following:

  1. How the patient was critically ill
  2. What you did for the patient
  3. The cumulative critical care time spent on direct and indirect patient care time is a key component

Try to document the following points, when applicable:

  1. Severity of illness and potential for decompensation
  2. Vital signs (hypotension, hypoxia, etc.) and how these changed through the case
  3. Tests performed and your interpretation of the results
  4. Treatments provided, including supplemental oxygen, IV fluids, medications, blood transfusions, burn/wound care
  5. Procedures performed
  6. Re-assessments of the patient’s status and response to interventions
  7. Conversations with EMS, the patient, the patient’s family or surrogate decision makers, nursing home personnel, consultants, and admitting teams
  8. Information retrieved by chart review and how this impacted patient care

Sample Critical Care Procedure Note

Authorized and Performed by: MD Name

Total critical care time: Approximately 36 minutes

Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient’s response to treatment; frequent reassessment; and, discussions with other providers.

This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time.

Please see MDM section and the rest of the note for further information on patient assessment and treatment