# Critical Care billing for emergency in office?



## twebber68 (Feb 3, 2009)

We have a physician who is wanting to bill for Critical Care for a patient who had a syncopal incident in our clinic before his appointment. The physician documented that he spent 45 minutes directing the care of the patient while they did EKG and such. Can you bill Critical Care outside of the Hospital Setting? The CPT book wasn't very clear.


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## mkj2486 (Feb 4, 2009)

Read CPT's description of a critical illness below.  Does this sound like what the patient's condition was?  You only stated a syncopial incident in your message.  I do not believe that constitutes a critical illness, but you didn't provide much information. 

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 function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient's condition continues to require the level of physician attention described above.


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## EARREYGUE (Feb 4, 2009)

Maybe you could bill 99058 in addition to the E&M and other service preformed? 

Just a thought=)


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## sborpa (Feb 4, 2009)

you can in an office setting, we use it for asthma attacks where really the patient is critical.  I have also seen it used for a bee sting when the patient was going into shock. see desc in mkj2486 reply for description.


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## Lisa Bledsoe (Feb 4, 2009)

That's not a bad suggestion EARREYGUE.  I don't think that CC codes can be reported in the office setting.  I would be more inclined to code based on time (if the documentation supports the time component) in addition to other services.  CPT is not clear on the setting per se, but I _believe_ the intent of the codes is to be used in a hospital setting.


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## FTessaBartels (Feb 4, 2009)

*I'd like to see the documentation*

I'd like to see the documentation to ensure that this was truly critical care.

If it isn't, then I like EARREYGUE's suggestion of using 99058 in addition to your E/M, etc.

If it IS truly critical care, then I believe you can code it as such. Patients can (and do) suffer life-threatening episodes when they are not in the hospital; if the physician is performing critical care he should be able to code it as such. 

One would wonder, however, why 9-1-1 wasn't called and the patient transported to the hospital if he was critically ill ... 

F Tessa Bartels, CPC, CEMC


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## RebeccaWoodward* (Feb 4, 2009)

Tessa,

Your view intrigues me. 

Patient arrives to practice with sore throat.  During the visit, the patient's throat became swollen, thus cutting off his air supply.  He coded.  All attempts were made to revive him.  What is your recommendation for this type of situation?


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## FTessaBartels (Feb 4, 2009)

*Critically Ill patient*

If the patient is critically ill, and you are providing critical care - *for at least 30 minutes* -  you can use the critical care code.  If the time isn't met then code the appropriate level E/M, any procedure(s) (e.g. CPR), and 99058 might be appropriate as well (I've never used that code myself).

Note that if you are using critical care, the time for procedures cannot be included in the critical care time. 

Be prepared to get a denial due to place of service since it's not usual to have critical care outside a hospital (or ER) setting. But your documentation should support your appeal. 

F Tessa Bartels, CPC, CEMC


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## RebeccaWoodward* (Feb 5, 2009)

Thanks Tessa...

To be quite honest, I never thought of using CC in the office setting.  Thanks for your input.


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## Lisa Bledsoe (Feb 5, 2009)

I admire and value your comments Tessa and Rebecca (in all posts).  I am one who would not recommend coding CC in the office as _I don't believe _it will be paid for the place of service.  If we could find the *cold hard fact *of what POS CC can be coded for, I would change my opinion in an instant.

Kudos to both of you on your knowledge and valuable input in this forum.  I am proud to part of those posts with you both!   

Lisa


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## RebeccaWoodward* (Feb 5, 2009)

Likewise Lisa...I don't know what I would do without you guys!  I rave about the folks on here and everyone's knowledge.  Your employers are lucky to have you.

I'm not sure how I feel about CC in the office setting. I'm going to do some research on this.  If I find anything, I'll post it.  I love a good challange.  

Have a wonderful day!


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## FTessaBartels (Feb 5, 2009)

*Great Forum*

Thanks and Kudos to all of you. I just can't tell you guys - Lisa, Rebecca, Mary, Donna, et al - *how* much this forum enhances my profesional life. 

As to THIS question ... Our practice *is* in a hospital setting. All our clinics are hospital based clinics, so if this situation happened we would definitely be billing critical care. We talk about "office visits," but we use the (22) POS (hospital outpatient) for them.

F Tessa Bartels, CPC, CEMC


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