ED Coding and Reimbursement Alert

3 hang-ups could lose you $240 per session

Before you decide not to submit a claim for critical care services based on a patient's location or time spent in the ED, read this to find out whether your claim falls prey to a reimbursement falsehood.

Myth #1: For us to bill for critical care time, the patient must be in a critical care unit.

Real deal: Critical care services aren't specific to a patient's location, but rather a condition that requires a specific type of physician care, says Barbara Cole, BSN, RN, CPC, president of ProTech Reimbursement Services, a national firm specializing in emergency medicine professional and technical coding in Collegeville, Pa. "Routine physician visits to stabilize patients in an ICU do not necessarily warrant billing critical care time," she says.

Myth #2: Because a patient spent a long time in our ED, the physician has the right to bill for critical care services.

Real deal: The classic example that debunks this misconception: the drunk patient with whom the ED physician spends four hours. When you're deciding whether you can bill critical care, what's important is that the service meets clinical criteria for these services - which aren't just based on time spent.

Myth #3: The physician must remain at the patient's bedside in order for us to bill critical care.

Real deal: The physician doesn't need to be at the patient's bedside for the services to warrant critical care codes, Cole says. But he does need to be doing work that directly relates to that patient's care.

For example, "the physician cannot be treating other patients at the same time the critical care is requested," she says. The physician must devote his full attention to the care of the patient during critical care minutes, but the time doesn't have to be continuous.