Question: The documentation in a patient's chart indicates that one of our endocrinologists visited a diabetic patient in the intensive care unit (ICU). Does this mean I should report a critical care code for these services?
Montana Subscriber
Answer: No, you should never assume that a physician's services were critical care just because the patient is in an ICU or critical care unit (CCU). A patient in the ICU may no longer be in "critical" condition when your physician sees her.
Depending on your physician's documentation, this scenario may merit a critical care code (99291-99292). But if the patient isn't in critical condition, the correct code may be either initial hospital care (99221-99223) or subsequent hospital care (99231-99233), depending on whether this is the physician's first or subsequent encounter with the patient.
To make sure you identify critical care correctly every time, look for two key indicators: evidence of the patient's critical condition and time.
Critical condition is necessary: The patient must be "critically ill or critically injured," according to CPT. A patient in critical condition suffers from impairment of "one or more vital organ systems" and faces "a high probability of imminent or life-threatening deterioration," CPT states. Therefore, a physician administering critical care will engage in high-complexity decision-making to sustain the patient's life and prevent further deterioration of the patient's condition.
Combine all reported times: Your physician needs to document the start and stop time of every critical care session with the patient. Documentation of time is crucial because without it you cannot bill critical care codes. Critical care services include both face-to-face patient time and time spent elsewhere on the floor or unit tending to the patient's care. However, CPT states the physician must be "immediately available to the patient." Critical care does not include time the physician spends in other units or off the floor tending to the patient's care needs.
Example: If the physician's notes state he spent 90 minutes on critical care in the morning and another 30 minutes in the afternoon, you should report a total of 120 minutes of critical care services with 99291 (for the first 74 minutes) and two units of add-on code 99292 (for the additional 46 minutes).
Not so fast: The key is that you can't round up with time. Code 99291 is for the first 30-74 minutes of critical care. So if your physician performs a total of less than 30 minutes of critical care, you cannot report 99291 for the service. You would have to report the appropriate-level E/M code instead - most likely an initial or subsequent hospital care code.
- The answers to the Reader Questions and You Be the Coder were provided and/or reviewed by Judy Richardson, MSA, RN, CCS-P, senior consultant, Hill & Associates in Wilmington, N.C.; and Anthony Azzi, MD, clinical endocrinologist with Raleigh Endocrine Associates in Raleigh, N.C.
