The Documentation-Coding Connection

Billing and documenting critical care

By Myra Wiles, CPC
Physician Reimbursement Specialist
Administrative Consultant Service Inc.
Shawnee, OK

When does critical care become just another emergency department (ED) visit? When you fail to document it properly. You may do all the right things and have a patient in crisis, but if the paperwork isn’t done properly, you don’t get paid for your efforts.

Many physicians think that if the patient is in ICU or CCU, they should bill those services with critical care codes. Others imagine that you can bill critical care in the ED if the patient dies or comes in via ambulance in critical condition. This is not true. Critical care is not a place of service; it is a type of service. While the care most often occurs in ICU or CCU, it can occur in the ED, a regular hospital floor or a skilled nursing facility. We personally know of one instance in which it occurred in a clinic waiting room. And while the patient’s condition must be critical (or imminently so), it is not the only criteria to be met to bill critical care services.

Critical care codes should be used to describe situations in which the physician is personally caring for or directing care of a patient that is critically ill or injured. There should be highly complex decision making to assess, manipulate and manage this patient who likely has impairment of one or more vital organ systems and faces imminent life-threatening deterioration without your involvement.

Documentation

Proper documentation is not difficult, but is seldom found. Three things must be well documented. Omit any of them and you can’t bill critical care.

• Patient condition — The chart should show that the patient’s condition is deteriorating or is likely to do so without intervention. The auditor will look for conditions such as circulatory failure, central nervous system failure, shock, renal, hepatic, metabolic and/or respiratory failure, etc.

• Time spent in care — How long were you there? The time doesn’t have to be continuous, but it must exceed 30 minutes for the day during which you devoted your full attention to the patient. You can show this as your exact times in and out or approximate how long you were involved in care. (Caution: Don’t rely on your nursing staff or anyone else to document this fact for you.)

What activities can be included in the time calculation? Services such as:

— Time spent at bedside caring for the patient.

— Time spent in the unit or at the nurse’s station engaged in work directly related to care of the patient. This includes reviewing test results, documenting charts or discussing care with other medical staff. (Note: Time spent in activities that occur outside of the unit or off the floor may not be included in the critical care calculation since you were not immediately available to the patient.)

If the patient is unable or clinically incompetent to participate in discussions, time spent with family members or other decision makers to obtain a history, reviewing prognosis or discussing treatment limitations or options, provided that the conversation bears directly on the management of the patient. However, time spent in activities that do not directly contribute to care of the patient (team conferences, courtesy or compassionate care for the family) may not be included — even if they happen in the unit.

— Time spent performing procedures that will be separately reported (such as CPR, endotracheal intubation, insertion of Swan-Ganz catheter, etc.) should be excluded from your time calculation.

• Activities involved — It’s not enough to just show the patient’s condition was critical. Critical care can be billed only if both the patient’s condition and the treatment provided meet the above criteria. Thus, your note should specifically state which of the above services were provided during your encounter.

• Who can record it and where — Some facilities keep very detailed logs of activities occurring during critical care times — much like the Code Blue logs that are kept. Those critical care notes document who was present and what was being done. While this certainly helps, it should not be relied on to document your physician services since many of those services occur away from the patient bedside and without involvement of other team members. Thus, the physician should record in the progress note those facts necessary to support his/her services.

Bill it right

Codes 99291 and 99292 should be used to bill for critical care activities. The CPT has an excellent chart that shows what codes should be billed based upon how long you were with the patient. Use it, but keep these rules in mind when billing those codes.

Only one physician can bill for a specific episode of critical care. This is true even if two physicians of different specialty are involved at the same encounter. If two physicians bill for different episodes of critical care on a given day, they should be prepared to submit notes documenting that care was provided at separate times. (Don’t forget that different of the same specialty in the same clinic are considered one physician.)

Code 99291 represents the first hour of critical care and should be billed only once per day by the physician.

Do NOT bill extra for services such as reading chest X-rays or EKGs, ventilator management, pulse oximetry, blood gases, analyzing data stored in computers, gastric intubation, temporary transcutaneous pacing, and insertion of simple vascular access devices such as IVs.

DO bill extra for services such as CPR (that you do), endotracheal intubation, insertion of complex vascular access devices and similar services. Be sure to add modifier –25 to the critical care codes if you bill any of these procedures to avoid denial of the critical care as a bundled service.

Don’t bill separately for a hospital visit on this date unless that other visit occurred at a separate encounter during the day that was not included in this critical care calculation. Such a visit must be fully documented to support the E&M code you bill for the visit.

Be sure the diagnosis code you use on your claim reflects the severity of the patient’s condition. It may have a bearing on coverage.

Don’t bill the 99291 or 99292 for time the physician spends during the transport of critically ill or injured patients to another facility. Instead, use 99289 and 99290.

Sample note

"Patient critical with multiple trauma due to MVA. I directed CPR and inserted T-tube. X-rays and labs reviewed. Orders written & IVs placed. Discussion with family about pt’s condition and decision made to proceed with care. Calls were made requesting consults from orthopedics, neurosurgery, and pulmonology. Dr Smith called to admit. Total time in care: 80 minutes, excluding time spent in above procedures."

What can you bill? You bill for:

  • CPR (92950);
  • Placement of T-tube (31500);
  • Critical care (99291-25 and 99292-25).