Reader Question: Critical Care Under APCs

Question: Under APCs, can I bill for critical-care time in the emergency department (ED) if it is documented by the ED nursing staff, but not by the ED physician? If so, how should this be documented by the nursing staff?

Agnes Murray
Philadelphia

Answer: For the definition of critical care (99291), facilities are instructed in the outpatient prospective payment system (OPPS) final rule to see the AMAs CPT 2000 Coding Manual for the definition of this code. The CPT manual states that critical care is the direct delivery by a physician(s) of medical care for a critically ill or injured patient and time spent with the individual patient should be recorded in the patients record.

This instruction appears to make physician involvement and documentation a requirement for facility reporting of critical-care services.

It should be noted, however, that according to the Health Care Financing Administration, the national Correct Coding Initiative (CCI) edits for services that are included in critical care relate to physician services only. Therefore, the critical care edits have been removed from the CCI edits for ambulatory payment classifications (APCs).

All procedures performed and documented may be reported by the facility in addition to a critical-care code, except for those procedures specifically bundled under critical care.


- Published on 2000-11-01