# Critical Care billing in the ER



## prallapalli (Feb 8, 2011)

If a patient was brought in by ambulance on 2/1 to ER and he was intubated and monitored in the ER for 28 hours until the weather was safe enough for the ambulance to transfer him to a higher care facility can a professional fee for Critical Care be billed?  Can anyone provide me with information on Critical Care?


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## jimbo1231 (Feb 11, 2011)

*Critical Care*

You might want to look at the CC Guidelines preceeding the codes in the CPT Manual. I would need to see the record, but it's unlikely to me that holding a patient for 28 hours even if intubated until the weather is better is 28 hours of CC. Was there some intervention to prevent the " high probability of immient or life threatening deterioration"? This looks more like an Observation scenario with maybe some CC at the beginning. But 28 hours is unlikely but not impossibe.

Jim S.


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## FTessaBartels (Feb 14, 2011)

*Physician must be face-to-face for Critical Care*

During that 28 hours, you can only bill for the times the physician was at the bedside, face-to-face with the patient, providing critical care.  This means that the ED doc is going to have to have recorded in/out times throughout the patient's stay in the facility. 

The patient must be critically ill. AND the care provided must be face-to-face critical care of at least 30 minutes duration. 

Once you cross past midnight, the clock starts over.  So for a patient who came in at 11:20 pm on 01-10-11 and was finally transferred out at 03.20 am on 01-12-11 ... FOR ARGUMENT'S SAKE let's say ER physician provided direct critical care from 11:20 pm to 12:15 am on 01-11-11.  ER physician also came in periodically for 10-15 minutes per visit over the next day ... let's say a total of 80 minutes critical care documented on 01-11-11. Then documented  another 40 minutes of critical care on the morning of 01-12-11 before the patient was transferred out.   For THIS SCENARIO you would code 99291 on 01-10-11, 99291 and 99292 on 01-11-11 and 99291 on 01-12-11.

Obviously you are going to have to deal with shift changes, so you need to make a decision on who gets to bill for the total time on 01-11-11, because you can bill out only under ONE ER doctor's name per day.  

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## jimbo1231 (Feb 16, 2011)

*Very Helpful*

Tessa,

That is very helpful for those tricky overnighters. But I want to make sure we are clear on what is considered CC time. CPT and to my knowledge CMS actually doesn't require bedside face to face time for CC. They do require "time spent engaged in work directly related to the individual patient care whether the time was spent at the immediate bed side  or elsewhere on the floor or unit". CPT then sites several non bedside activities that can be counted toward CC time. These include reviewing test results,discussing patient with other staff, documenting medical record etc. Of course all of this work must be on the floor and unit and directly related to the critically ill patient. Also time for separately billed procedures such as ET intubation must be reduced from CC time.
I also like the idea of tring to get physicians to document CC time in some kind of time based format. But this isn't required to code CC, just that they document the overall time spent providing CC.

Jim S.


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## FTessaBartels (Feb 18, 2011)

*CMS vs CPT*

CMS DOES require that the time be spent in at-the-bedside, direct face-to-face contact.

CPT allows you to count unit/floor time.  BUT only that unit/floor time that is specifically related to THIS patient.  So if your ER doctor is at the nurses station review X-rays from four different patients only the 3 minutes he spends reviewing Xrays from the critically ill patient counts as critical care time.  

You are right that only the total time needs to be documented, but you wll find it easier to defend the unusual cases (and this scenario certainly is unusual), if the physician has recorded in/out time in the patient's chart.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## jimbo1231 (Feb 18, 2011)

*CC Time*

"The time spent providing critical care services must be spent at the immediate bedside or elsewhere on the floor or unit as long as the physician is immediately available to the patient. Therefore, the physician cannot provide services to any other patient during the..."

This is the definition that I have seen pretty much on Medicare transmittals and OIG directives. Certainly the time must be spent on direct care for the critically ill patient. But neither CPT nor CMS is looking fo "bedside" time in the strict sense. Both realize that Critical Care is a team effort whether at the bedside or elsewhere on that unit as long as it directly relates to patient care. In most EDs the physician being at a bed side for extended periods is an unrealistic scenario.
I agree about the time documentation. Actual time increments is the most defensible scenario.

Jim


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## sam_son  (Feb 22, 2011)

*CC*

Jim & F Tessa Bartels

Both of you had given a valuable informations. I think when combine both the informations it will gives answer to many questions..

Thanks both of you


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