Understand Critical Care Before You Code


A solid understanding of guidelines and COVID-19-related complexities will limit claim denials and audits.

Deciphering documentation to determine what qualifies as critical care services can be challenging for medical coders and auditors. With limited critical care codes available for assignment, reporting may appear relatively straightforward at first glance. However, there are many considerations that coders need to be familiar with to ensure compliant coding for accurate revenue. Taking a deep dive into Medicare and CPT® guidelines relating to documentation requirements for medical necessity, multiple physicians, and the reporting of additional services is essential in determining code assignment. In addition to understanding the requirements, variation in documentation and the complex nature of COVID-19 can make it difficult to determine if the patient qualifies for critical care services. So, what is key in critical care? Let’s take a closer look.

What Qualifies as Critical Care?

The Centers for Medicare & Medicaid Services (CMS) defines critical care services as direct physician care of “a 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” provided in any location. For Medicare, medical necessity is achieved when both organ or system failure — such as circulatory, respiratory, renal, central nervous system, hepatic, and/or metabolic failure — and a high probability of imminent or life-threatening deterioration are present. For coding purposes, CPT® requires a high complexity of medical decision making (MDM) in addition to reporting critical care.

For example, a patient with a severe case of COVID-19 may present single or multisystem failure, such as cardiogenic shock and renal failure, but in addition to the system failure, documentation must show a high probability of imminent or life-threatening deterioration in the patient’s condition. If the provider documents that the patient’s condition is stable, has no complaints, was taken off the ventilator and put on room air, or will be discharged tomorrow, there is a low likelihood that the encounter meets either Medicare’s or CPT®’s definition of critical care services.

Solve the Multiple Physician Dilemma

When more than one provider is caring for a patient, each needs to document their management of one or more illnesses or injuries, either individually or in part. If the providers are in the same specialty, only one may bill for services during the same time period. However, nonconsecutive time spent by providers in the same specialty may be added together and reported under one provider. Fleshing this out further, separate specialties treating critical conditions may each bill for their time.

Be aware of instances, however, where two specialists are documenting their time as critical care, but only one is actually addressing system failure. For example, a pulmonologist is managing acute hypoxic respiratory failure and emergently places the patient on a ventilator in the intensive care unit (ICU), while a cardiologist is managing the patient’s cardiomyopathy and uncontrolled hypertension. In this case, only the pulmonologist should receive payment for critical care services.

Remember: Just because a patient with COVID-19 is in the ICU receiving critical care from one specialist does not mean all services the patient receives are critical care services.

Time Considerations

Evaluation, care, and management of the patient at the bedside or on the floor/unit on a per-day basis can be continuous or intermittent. Discussion with other physicians/care team, review of labs and other diagnostic data, dictation, and bundled procedures all count toward total time. (Note: The physician must be immediately available and cannot be overseeing the care of any other patients for the time to count toward the critical care.) Total time also includes time spent with family or decision-makers reporting on the patient’s condition or obtaining a medical history and decision making if the patient is unable to participate. For a patient with COVID-19, once the disease process has become severe enough to require sedation and intubation, decision-making by another responsible source can also be counted toward the time.

However, if the time spent with the patient providing critical care services is less than the defined time for the code, assign only a code for the appropriate evaluation and management (E/M) service. For example, a patient was admitted to the ICU, and the next day, a provider sees the patient who has COVID-19, acute hypoxic respiratory failure, and acute-on-chronic renal failure. The provider documents the critical care interventions taken and the time as 23 minutes. In this case, code assignment should be for subsequent hospital care, not critical care.

Differentiate Separate vs. Bundled Procedures

Although bundled procedures can be counted toward the critical care time, separate procedures cannot. It would be inappropriate to bill twice, or “double-dip,” for the work. Documentation should clearly differentiate where the provider’s time was spent. Be aware of what has been documented when ventilator management is performed for COVID-19 cases since these are bundled services.

Bundled procedures include interpretation of cardiac output measurements, chest X-rays (professional component), blood draw, blood gases, and data stored electronically (e.g., electrocardiograms, blood pressures, laboratory results), gastric intubation, pulse oximetry, temporary transcutaneous pacing, ventilator management, and vascular access procedures.

All other procedures are separately reportable when medically necessary, and modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service may be appended to the critical care code.

Be Ready for Scrutiny

Payments for critical care services are significantly higher, which leads to reviews from Medicare and other payers. Auditing for services related to COVID-19 has been a massive point of discussion during the public health emergency. Don’t let your guard down; be ready for audits relating to other services provided during this time, as well.

Critical care is complex and understanding these services and how to code and bill them properly requires education and regular audits — whether performed internally or by a third-party vendor such as AAPC Services — to minimize potential revenue risks and ensure compliance with reporting guidelines and regulations.

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