10 November 2008

Critical Care

The practice of medicine, as a business, is a challenging model. You have minimal control over your prices, no ability to negotiate with your biggest payers (the governmental ones, that is), and limited leverage to contract with commercial payers. In our specialty, you also know that a certain significant but unpredictable fraction of your patients will not be paying you at all, and you have to staff to an expected patient volume, but you have no real ability to control your volume. Compensation for services from all payers is perpetually squeezed downward, and given the narrow focus of our specialty, it is difficult to diversify the business model.

So, if you want to run a profitable and successful practice, you need to focus on the internal efficiencies to maximize your revenue. The universal inefficiency in EM practices is physician documentation; this inefficiency is, of course, also an opportunity to improve, and thereby increase your revenue. For most practices, 85% of revenue can be accounted for with only seven codes: 9928x and 9929x in coding jargon, commonly referred to as the Evaluation and Management (E/M) codes and Critical Care (CC). A lot of attention is paid to the E/M coding requirements, as they are onerous and failure to comply will absolutely sink your business. But Critical Care is often overlooked, and this underutilized code can provide a significant profit margin for your practice.

As you can see, one hour of Critical Care is worth about 25% more, per case, than a Level 5 E/M charge. Of course, your experience may vary depending on your payer mix, collection rate, and current coding levels, but optimizing your CC coding has the potential to add 2-5% to your total revenue. That may not sound like much, but those are totally "free" dollars -- there is no added cost to generate that additional revenue, so it goes directly to provider compensation. Depending on your practice's overhead, that may increase physician compensation by 3-9%.

So why don't Emergency Physicians routinely code for CC time? Well, many do, and the frequency with which this code is utilized in the ED has been steadily increasing:

(Source: BESS data, representing Medicare patients only.) Some of this increase, however, may be due to the increasing practice of "boarding" critical patients in the ER waiting for inpatient beds. Some may be due to the increasing age, complexity, and acuity of patients in the ER. But it is undeniable that Emergency Physicians are catching on to the value of appropriate utilization of the CC code.

Many challenges remain to widespread adoption of this code. Many EPs are just unaware of the value of this code and the opportunity it represents. Emergency Medicine residencies do a terrible job of educating their physicians in this area, which puts young physicians at risk of losing income as they get up to speed with the business of medicine. Additionally, many EPs are a bit jaded and undervalue their services, not recognizing when they have provided critical care.

Furthermore, CC is a unique code in that it requires a break in the routine documentation flow. Unlike almost every other procedural code used in the ER, for CC, the physician must explicitly and affirmatively ask for it. For every other code, the professional coder can infer from the record what was done and apply the appropriate codes, but CC requires that the EP remember to claim it, and document in a very specific manner what was done in order to compliantly receive credit for the service provided. Critical care requires that the doctor record the time spent, the "unbundled" associated procedures, and a defensible summary of the critical illness and interventions. While not difficult, these requirements are different from those for the other 90% of patients seen in the ED, and require the EP to approach the record in a different manner that they otherwise do.

So what is "Critical Care" anyway?
The nice thing is that Medicare provided a very loose and vague definition, and left it to physicians to decide on a case by case basis. According to the most recent Medicare definition (PDF) : Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. 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. Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

There are a three key requirements which must be met for critical care:
  • Time.
  • Medical Necessity/Criticality.
  • Interventions.
Let's address these individually.

This is a time-based code; the physician must document the total time spent in the care of this patient. The first 30-60 minutes will be billed as code 99291, and subsequent half hours will each be billed as a 99292. The time element is the most commonly missed. Frequently physicians will provide wonderful documentation of their critical care services, but failure to explicitly record the time spent will result in the case reverting to an E/M code. Coders are not allow to infer from the record how much critical care time the patient received.

The time requirement is cumulative, meaning it need not be continuous. So if the patient is in the Department for six hours, but you spent 90 minutes over this time frame devoted to the patient's care, you may bill for 90 minutes of critical care. This does includes time not at the bedside, and explicitly includes activities such as lab review, consultations, family decision-making, and documentation. You do not need to explicitly break down a line-item summary of the activities you engaged in.

A key requirement is that you must be "immediately available" to the patient during this time. For this reason, time spent off the unit cannot be included in CC time. This effectively means that providing prehospital control to EMS can not count towards the total time.

This is the huge subjective element in CC today, and may represent the greatest opportunity (as well as the greatest risk) for your practice. CPT provides examples of critical care which are intended to represent the "mid-range" of CC services. However, CPT also provides examples of Level 5 E/M cases which appear to meet the definition of critical care as it is currently understood. For example, any patient who experiences acute respiratory or circulatory failure requiring ventilatory support or vasopressors is clearly critical. However, a patient with unstable angina requiring intravenous nitrates, beta blockers, and anticoagulants certainly also meets the definition. Or a patient with a GI bleed requiring fluids resuscitation and transfusion. For that matter, the current definition of sepsis/SIRS is quite broad, and patients with SIRS, even early SIRS, meet the broad definition of "high probability of deterioration."

The key here is to recognize that criticality extends far beyond the intubated patient to a wide variety of conditions.

In order to fully justify the service you are claiming, it is necessary to have done something for the patient. That may include anything from heroic life-sustaining measures to very simple measures such as crystalloid fluid resuscitation, so long as the criticality requirements are met. The CPT definition clearly includes complex decision-making as meeting this requirement. It is, however, more justifiable when there is a tangible and clearly identifiable intervention was performed which can be said to have averted or treated the patient's actual or potential deterioration.

What's not required for critical care is almost as important as what is required. The standard E/M components of HPI, ROS, Past/Family/Social History, etc are not required. While you omit them at your peril (from a medical liability point of view), these are not required elements of a critical care chart from a coding and billing perspective.

It is important to understand that a variety of procedures are included, or "bundled" into CC. These are: blood draws, peripheral IV placement, blood gas interpretation, NG placement, Pulse oximeter interpretation, ventilator management, transcutaneous pacing, and CXR interpretation. You may not bill separately for these items on a critical care patient. However, all other procedures still may be billed separately, including but not limited to: intubation, central line placement, EKG interpretation, cardioversion, tube thoracostomy, laceration repair, fracture care, lumbar puncture, etc etc etc. Be aware that CPR supervision is a separately billed service, and CPR time bust therefore be subtracted from your total Critical Care time. It is very important to explicitly note that the time you spent providing critical care services was "exclusive of all other separately billed services." Memorize that phrase and be certain to use it in every critical care dictation you do!

Compliance and Risk:
As Medicare's RAC process turns its attention to professional billing, it is predictable that this will draw its attention and that audits will result, especially in light of the increase in the utilization in these codes. As the standards are somewhat loose, how to demonstrate compliance is on everybody's mind. The key is, I think, to set standards in advance and consistently apply them, and to document explicitly the nature of the patient's criticality. In almost every critical care case, I include the statement that I felt the patient was at high risk of "X" to make it very clear to the coder (and any auditor) why I felt the patient was critical. Auditors generally give a fair amount of latitude to the judgment of the provider, so long as you explain your thoughts.

Supporting evidence of criticality which is helpful to highlight in your documentation might include:
  • Obvious problems like respiratory failure or circulatory failure.
  • Any organ system which has acutely failed (or may fail).
  • Significantly abnormal vital signs.
  • Shock, even early shock.
  • Acidosis.
  • Need for interventions such as central venous access, thoracostomy, cardioversion/defibrillation, transfusion of blood products, or the "ACLS" suite of IV medications.
  • Multi-system diagnoses (aka, your "Train wrecks") requiring highly complex medical decision-making.
  • Trauma patients with serious injuries.
  • Patients requiring ICU admission.
ICU admission may support the criticality of the patient, but is alone not sufficient, especially if the patient is admitted as an overflow patient, or as a chronic ventilator patient.

There is some debate regarding whether Critical Care may be justified based on the presentation alone, or whether an actual critical illness need be present. Consider, for example, a trauma patient whose injuries turn out to be non-life-threatening. Some claim that the patient, prospectively, was an unknown and had a high potential for deterioration. However, the guidelines state that "both the illness or injury and the treatment must meet the requirements." This requires that the patient has an actual illness/injury, not a potential one.

Conversely, there may be cases in which the patient is manifestly critically ill, but the EP does not actually provide direct treatment. For example, consider the stable patient who comes in with a cerebral hemorrhage. If all the EP does is order the CT and call the neurosurgeon, there was no critical care provided. If the patient required urgent blood pressure control, that would be different, but absent some intervention, Critical Care is not appropriate.

And there are some patients who are critical but do not meet the time requirements. In my institution, ST-Elevation MI's go very quickly to the cath lab, and are often in the ED for only fifteen or twenty minutes. While the illness is critical, and the intensity of service provided in that time is high, the time requirement is absolute, and these patients must be coded out as level 5's. (Using the "patient acuity" caveat for the ROS, of course.)

Frequently Asked Questions:
Can you code Critical Care on a patient who is subsequently discharged home?
Yes, but be cautious. A compliant chart would make it quite clear that the patient was indeed critical and that there was an intervention which changed the course of their illness. An auditor would likely be skeptical of CC on a discharged patient, so I would recommend that your documentation be bullet-proof in these events. The most common example I can think of would be an overdose requiring temporary airway management, and things of that sort.

Can Critical Care be billed as a shared service between physicians?
No. If two physicians of the same specialty within the same group both provide 30+ minutes of critical care on the same day, the first must be billed as 99291, with subsequent increments of 99292 as appropriate. If each physician accounts for only 15 minutes of time, it may not be combined.

Can an ER physician bill for an E/M service and Critical Care on the same calendar date?
Not for Medicare patients. CMS specifically prohibits this, for the ER E/M codes only. CPT guidelines will permit this, so long as the services provided are separately identifiable and discrete. Some commercial payers may recognize this, but it is fairly uncommon and often will be rejected by payers. If the patient presents prior to midnight and receives 30+ minutes of critical care both prior to and after midnight, two units of 99291 may be billed.

Can an attending bill for teaching time, or time spent by resident physicians?
Teaching time may not count towards Critical Care. However, the attending may bill for time spent supervising the resident so long as the attending is physically in the room with thepatient while the services are being provided, and documents: "(1) the time the teaching physician spent providing critical care, (2) that the patient was critically ill during the time the teaching physician saw the patient, (3) what made the patient critically ill, and (4) the nature of the treatment and management provided by the teaching physician." The attending may reference the resident's documentation for details.

Can a PA or Nurse Practitioner bill Critical Care time?
Yes, provided all the other guidelines are met. As with Physicians, this may not be billed as a shared service.

In summary, Critical Care is a valuable service which we provide to our patients, and it is correspondingly well-reimbursed. Most Emergency Department practices still do not utilize it as fully as is allowed, and optimizing your critical care coding can provide a valuable profit margin to your practice's bottom line. However, given the increasing attention to this code, future audits are all-but-certain, and it is essential to consider the compliance elements of this code and be certain that your documentation supports the value of the services you are providing to your patients.


  1. This is another article worthy of publication. Excellent work!

  2. You must have spent some time at the coding meetings at ACEP. These codes can be used by other physicians as well, and one of the misconceptions I frequently encounter is that you must be ICU trained to bill a CC code.
    I'm going to share your article with my group as well. Nice one!

  3. Matlatzinca,

    Yeah, I went to the Coding & Nomenclature Committee meeting -- "Where fun goes to die."

    CC can be billed by anyone, anywhere, even in the office setting, so long as the requirements are met.

  4. And your ending is why this is so frustrating for the admitting doctor. I can choose to bill an H&P or the critical care code. Many insurers won't pay both even if you wind up spending half the night in the ICU with patient. Or even worse is the patient admitted by a partner at 7am who crashes at 8pm when you are on-call and you don't get to bill a single penny for what you do.

  5. Great work shadow. Now. Tell me the last time an ED doctor spent 30 minutes of uninterrupted time at the bed side of a critically injured patient. Remember that 30 minutes must not be involved with any other patients. That means you can't be looking at the snot of a little kid during that 30 minutes. Critical care billing is all about the time spent. Less than 30 minutes= E&M, no matter how sick they are.

    anon 109. Not true at all. Every 30 minutes you spend past the first 75 minutes is billed out as a 99292. I remember billing out a 99291 and FIVE 99292's on one patient in the same day. And if your partner bills a 99291 and documents the time, and you come by you can bill the add on as many codes 99292 as the time you spend on them. Remember billing critical care codes is all about the time spent.

    And like Shadow says, you can bill them anywhere. You can bill them in your office if somebody shows up hypotensive and you spend 30 minutes coordinating care and evaluating them.

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  7. I will make one correction from your articel Shadow. You cannot bill a 99292 until you pass the 75 minute threshold. The first 30-60 minutes is a 99291. But you must spend 15 or more minutes for every next 1/2 hour to qualify for a 99292.

    SO the first 61 minutes is a 99291. The first 70 minutes is a 99291. The first 80 minutes is a 99291 plus one 99291. The first 110 minutes is a 99291 plus TWO 99292's. Remember, you have to pass the 15 minute marker to qualify for the next 99292.

  8. Happy & Anon 1:09,

    First of all, if you are the admitting doc, then you *can* bill critical care and an E/M on the same day. Only the ER E/M codes are not allowed to be billed on the same date.
    If you are an ER doc, and there is reason to want to bill both, then the higher code 99291 would take precedence, and only it should be billed (assuming that your billing office know what it's doing).
    Also, if you're up "half the night" in the ICU, chance is you're in the next calendar date -- another 99291!

    Happy -- the 30 minutes need not be continuous, and need not be all at the bedside. It's the aggregate of all the time you spent on the patient. For a reasonably sick person, they will meet the time requirement for sure. I don't usually spend 30 minutes at the bedside, but I bill plenty of CC!

    You are right about the times -- the explanation is that Medicare rounds down. So the first hour is 99291, but only if you spend 30 minutes. The second increment kicks in when you have spent 15 minutes beyond the first hour. So the effect is that 30-74 minutes = 99291, and 75-104 min = 99291 and 99292.

  9. Shadow. great discussion here. I'm going to link to it. A few other comments. I know that the 30 minutes can be split up and you don't have to be right at the bed side and that it can include all the other stuff you do like talking with family and other specialists and reviewing data. But my point was, that as an ED doc, you are constantly jumping from patient to patient. If you ever got audited and they asked to see a flow chart of your time involved in a critical care patient, and they were some how able to cross reference your stated time with other charts of other patients you saw on that day, you would likely have a hard time defending the 30 minutes, since I'm almost sure you don't document time in and time out for every critical care patient as you move from room to room. The chances they do that in depth of an audit is almost nil. However, with the new EMRs it gets easier and easier for big brother to track your place in time and space.

    As for some other clarifications. Remember for non ED codes, you can bill an E&M code (such as an admit code 99221-99223 or a consult code 99211-99215 or a hospital follow up code such as 99231-99233) and IF the patient decompensates later in the day, you can ALSO bill a critical care code(s) 99291 and/or 99292 and they will/should both get paid from the same calendar day. However, you cannot bill a critical care code 99291 and/or 99292 and then follow that with an E&M code such as the hospital follow up codes 99231-99233 on the same calendar day. That will get denied. You cannot also bill both critical care code and a discharge code 99238/99239 on the same day. Discharge codes will not be paid in conjunction with other codes. If you admit a critical patient (for example a drug overdose/hypotensive/tachycardia) at 3 am and by 5 pm they are extubated, playing computer games in the ICU and you want to discharge them, bill just the critical care code and not the discharge code for the obvious reason that the critical care code pays more. It may get audited because they are discharged within 24 hours of a critical care code, but who cares. The patient was critical when they came in and you did critical care work and did a fantastic job of getting them better guickly. If anything, you should get paid MORE than the critical care codes.

    Don't short change yourself. Ever. If the clowns at the Medicare National Bank want to set up rules, play by the rules and get paid by the rules.

    Remember also that as you stated previously some procedures are bundled into the critical care codes and can't be billed out separately. For those procedures that you can bill out separately, such as central lines and intubations, the time spent in doing these procedures CANNOT be included in the time you bill for critical care. It is important to document in the chart that "the time spent in performing my procedures was independent of my documented critical care time". That statement will go along way in preventing rejected claims based on the time factor.

  10. Happy,

    I see where you are coming from with the time issues. I don't worry about it too much since the time really is easy to defend. I think of it this way: If I average 2.0 patients per hour, that means the *typical* patient needs 30 minutes of care. Of course, every ankle sprain frees up that much more time for the more complex patients. Never mind the fact that most docs are there two+ hours after their shifts.

    From an audit point of view, it's unlikely that they would choose to attack the time issue, unless there was a doc billing 6 hours of time per shift! Too much work for too low of a yield. The criticality is the vulnerability for most ER docs, I think.

  11. When you get really good at managing sick patients, they don't seem so hard anymore. AFib, AMI, Sepsis, Hypoxemia, hypotension. It can seem easy to evaluate and manage.

    Many docs forget that just because something is easy to manage because you have lots of experience, doesn't make it less critical.

  12. This is Anon 1:09. While you are right that I may bill for the critical care time on the patient I see in the evening after my partner saw admitted them that morning, you are incorrect that I will ever get paid for it since we share a tax ID#. Now if I wanted to donate the money to my partner that is possible though I wonder what would happen if ever audited. I realize that is a separate issue.

    And to Happy's other point that is a little confusing. I can bill a hospital follow-up(99231-99233) and then later in the day bill a critical care code. But then later you say I cannot do the reverse. Do and bill for critical care from 1am-3am and then come in at 7:30 for their normal 'daily' visit and bill for it. Why is A then B OK but not B then A?

  13. Outstanding post; thank god the election is over!

    FWIW, all of my critical care patients seem to take exactly 35 minutes, except for the rare ones that take 80 minutes.

    Haha....word verification is "extra"

  14. anon, if you both practice the same policy of billing the add on codes for the other doc, over time, it should equal out. He bills for you. You bill for him. You both collect for work done.

    Also, on the same calendar day (from midnight to midnight) you CAN bill an E&M code followed by a critical care code because a stable patient can become unstable, However, you cannot bill a critical care code followed by an E&M code. You would instead bill the follow up critical care codes 99292 if you meet the 30 minute targets. That's just the way it is. If you bill a critical care code on admission at 1am-3am, and you come back for daily rounds at 7:30 am, you can not bill a hospital follow up code. You would have to bill the add on critical care codes 99292 if you meet the 30 minute time levels for each 99292.

  15. very helpful thank you.

    unfortunately, my residency program taught me next to nothing about billing/coding.

  16. Forgive me, but I think the only weakness in this article is the point of medical necessity. The criteria is actually pretty specific. Per CPT (2009): "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." Furthermore,Decision Health Coding Answer Book on Critical Care states, "The mere presence of a patient in an ICU or CCU, or the patient's use of a ventilator, is not sufficient to warrant billing critical care services." While critical care billing is certainly more lucrative for the physician, caution should be taken not to use these codes inappropriately, or all that increased reimbursement could easily go right back out on penalties and/or attorney's fees.

  17. Can you bill a critical care code for a patient that you operate on later....or put a bedside ventriculostomy in?

  18. Yes, the procedural service does not preclude an management service (or vice versa). I don't do a lot of ventriculostomies, but I do intubate, cardiovert, or do chest tubes on patients who also get critical care codes.

  19. E&M work you do BEFORE you do surgery can be billed out separate and independent of the global surgical fee. Fore example if you see a hospitalized patient ( do an consult) and then see them for 3 days and THEN decide to do surgery, you should be able to submit the consult E&M and the three days of follow up inpatient hospital codes AND the global fee surgery. And make sure you bill for the work you do. Otherwise you're not only screwing yourself, but the "curve" as well.

  20. 30-74 minutes 99291 x 1
    75-104 minutes 99291 and 99292 x 1
    105-134 minutes 99291 and 99292 x 2
    135-164 minutes 99291 and 99292 x 3
    165-194 minutes 99291 and 99292 x 4


  21. just stumbled on this post while searching to see if I can bill critical care for UA with nitro gtt. Newly out of EM residency and never learned this information. Thanks!

  22. I always found worth content here,Would like to visit again.Keep posting interesting articles like this..


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