ED Coding and Reimbursement Alert

Question: Our ED physician received a call from a rural hospital looking to transfer a patient with STEMI to our facility to be admitted to the cath lab. The physician spent 18 minutes in anticipation of the patient's arrival, arranging activation of cath lab and consulting with other providers. The patient arrives and is provided with critical care services and is admitted to the cath lab after 19 minutes. The doctor would like to bill 37 minutes of critical care.

I am conflicted as to whether to bill critical care. On the one hand, the doctor spent significant time emergently coordinating care for this patient. On the other, the patient was only physically present for 19 minutes. Does anyone one have any advice / experience with this type situation?

Maine Subscriber

Answer: CPT® is clear that the physician does not need to be at the bedside for every minute of critical care time reported as long as they are directly involved in care of the critically ill or injured patient. Sometimes a very efficient ED will move the patient to another venue, such as the cardiac catherization lab, before the minimum time threshold for critical care is met. In those scenarios, you should consider reporting a level 5 ED code, 99285 if appropriately documented, possibly invoking the acuity caveat.

Specifically to your question if the physician was directly consulting with other providers on that critically ill patient, you should be able to count some of that time in your critical care clock. Don't forget to include reasonable time spent in documenting the encounter even if it occurs shortly after the patient leaves for the cath lab.