ED Coding and Reimbursement Alert

Question: Thank you for your article last month on critical care coding. One question we have is when we should start the clock running to begin tallying critical care time. Is it as soon as the patient walks in? As soon as the doctor starts treating them? Or when they start realizing the care is “critical?”

Codify Subscriber

Answer: When coding for critical care, you cannot code for time spent in pre-hospital medical direction or coordination of care — activating alerts, setting up rooms/staff, etc. — prior to the patient arriving.

All E/M codes assume pre-work and this is built into the relative value. For instance, 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) includes 15 minutes of pre-service time according to the AMA’s RBRVS [resource-based relative value scale] database.

The American College of Emergency Physicians (ACEP) addresses this on its website, noting, “Physician time for critical care services encompasses time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere. For example, time spent can be at the bedside, reviewing test results, discussing the case with staff, documenting the medical record and time spent with family members (or surrogate decision makers) discussing specific treatment issues when the patient is unable or clinically incompetent to participate in providing history or making management decisions. The ‘critical care accrual clock’ pauses when separately reportable procedures or services are performed; these should not be included in the total time reported as critical care time …”

Therefore, once the physician specifically starts performing care that meets the definition of critical care, you should start the clock – but you must pause it when performing separately reportable services.