ED Coding and Reimbursement Alert

Check for documented time and acuity of the presenting problem to inform your critical care choice.

Critical care coding is different from the ED E/M services in that it does not have the traditional documentation requirements for history, physical exam, and medical decision making; however that can make it harder for coders to determine when the threshold for reporting critical care is achieved. CPT^® is clear about the required time units that must be documented, but how do you determine if the patient is really critically ill or injured based on chart documentation? These common ED case examples will help

Let's Start With the Basics

CPT^® defines critical care as "an injury or illness that acutely impairs one or more vital organ systems such that there is high probability of imminent or life threatening deterioration in the patient's condition," says Rebecca Parker, MD, FACEP, president of Team Parker LLC, an ED coding and billing consulting company in Chicago, IL, and president of the American College of Emergency Physicians. CPT^® also states that a minimum threshold of 30 minutes is required, both in the code descriptor itself and in the time threshold chart in the critical care section preamble, 99291 (Critical care, evaluation and management of the critically ill or injured patient; first 30-74 minutes) or +99292 (... each additional 30 minutes [List separately in addition to code for primary service]).

An accurate time statement is required. That may include the exact number of minutes that were spent providing critical care or based on a time range if clinical conditions make documentation of actual minutes difficult. You may see the time documented net of performing separately billable procedures. However, don't forget to check on those common ED procedures or diagnostic tests that are already bundled into critical care. The CPT^® critical care preamble includes a specific list of services that are bundled in to code 99291 and should not be reported separately. These include:

The interpretation of cardiac output measurements (93561, 93562);
Pulse oximetry (94760, 94761, 94762);
Chest x-rays, professional component (71010, 71015, 71020);
Blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data (99090);
Gastric intubation (43752, 43753);
Transcutaneous pacing (92953);
Ventilator management (94002-94004, 94660, 94662); and
Peripheral vascular access procedures (36000, 36410, 36415, 36591, 36600).

Tip: When your physician provides any of the above services during a critical care session, do not report them separately, and don't deduct the time spent performing them from your documented critical care time, Parker says.

Know When A Patient Is Critically Ill or Injured?

Chart documentation should contain a clear clinical indication that the patient meets critical care criteria. You can use the CPT^® preamble language to guide this decision process. In educating our providers, Parker emphasizes that they must answer yes to the following three questions:

1. Is at least one vital organ system impaired?
2. Is there a high probability of imminent, life-threatening deterioration?
3. Did you intervene to prevent further deterioration of the patient's condition?

That "high probability" clause is key. When determining whether or not a patient is critically ill or injured, the physician should consider the likelihood that they would have a clinically significant deterioration if nothing was done in the next hour. If the probability for imminent or life threatening deterioration is high, critical care may be appropriate to report the service, Parker says.

Your chart documentation of the ED Course should establish medical necessity and should support high complexity medical decision making. Be sure to consider diagnostic and therapeutic interventions performed or considered even if no positive response is generated. Documentation of serial assessments is also suggestive of a high acuity patient encounter, Parker says.

Disposition is Another Clue for Critical Care

The disposition of the patient after the ED encounter is another documented element that suggests that critical care be considered.

The following documented dispositions would suggest critical care:

• ICU admit
• Direct to OR
• Death in the ED
• Disposition that would typically include documentation of rapid improvement in the patient's condition include: Floor or telemetry admit
• Discharged home

If the patient was admitted (based on medical necessity) to ICU or immediate disposition to OR, you should strongly consider critical care, Parker explains

Think Twice if Documentation Paints a Different Sense Of Treatment Urgency

On the other hand, documentation like the following suggests that the service may not be critical care

Patient in no apparent distress - though keep in mind this is at times unintentionally a component of the record

Normal vital signs
"Resting comfortably"

Documentation That is Not Clearly Critical Care Or Not Critical Care

Minimally documented or a benign ED Course that does not support medical necessity for critical care

Abnormal lab values alone do not support critical care unless medical decision making reflects high complexity and initiation of assessment/treatment for prevention of serious deterioration

Consider adding a medical necessity statement if scenarios like those above justify critical care, Parker says.

Medical Necessity statements could include:

"Organ system(s) at risk is..."
"What and why" as far as diagnostic and/or therapeutic interventions undertaken by the physician
Critical lab, imaging EKG findings documented and significance addressed
ED Course reflects frequent re-assessments and decision-making
Likelihood of life-threatening deterioration
Also from a risk management and compliance approach, Parker suggests reviewing:
Critical care time over 2 hours in duration
Questionable medical necessity
The importance of "Medical Necessity" note in questionable cases.