DRG Coding Advisor: Critical care billing requires careful documentation

Assessment of patient condition and treatment received are determining factors

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 for 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 the intensive care unit (ICU) or critical care unit (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 critical care most often occurs in the ICU or the CCU, it can occur in the ED, on a regular hospital floor, or in a skilled nursing facility. I know of one instance when it occurred in a clinic waiting room. And while the patient’s condition must be critical (or imminently so), that is not the only criterion to be met to bill critical care services.

Highly complex decision-making required

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 required 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.

Proper documentation is not difficult, but it is seldom found in the medical record. There are three things that must be well-documented in order to 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 such conditions as circulatory failure; central nervous system failure; shock; or renal, hepatic, metabolic, or respiratory failure.
  • 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 you can 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.)

Time spent outside unit doesn’t count

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 the unit or off the floor may not be included in the critical care calculation, because 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, review prognosis, or discuss treatment limitations or options should be included, 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, such as 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 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.

Bill it right

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, because many of those services are provided 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 or her services.

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 the CPT chart, 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 specialties 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 physicians 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 like IVs.

— DO bill extra for services such as CPR (that you perform), 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 evaluation and management code you bill for the visit.

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

— Don’t bill 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 and 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).