EM Coding Alert

Question: Can we report critical care for a patient with suicidal ideation? Our coders have discussed this in depth and have determined that suicidal patients should not be coded as critical care because “psychiatric” is not an organ system that could be impaired such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. What do you think?

South Dakota Subscriber

Answer: Critical could be reported if the 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) time thresholds were met and there were interventions on behalf of a patient in imminent danger of harm. If the patient remains in the ED for an extended period of time, an observation code may be the more appropriate choice to describe multiple evaluations and interventions over time until the patient’s disposition can be determined, though not simply for holding or convenience while waiting for a bed.

Perhaps the difference of opinion is over the definition of suicidal ideation (considering or obsessing about suicide), rather than an immediate threat (I bought a gun and I’m going to kill myself if you can’t help me) or an actual suicide attempt that caused serious injury. The former is not likely critical care and the second certainly could be. If the suicide attempt has left the patient critically ill or injured and the treatment is stabilization or its attempt, that could be a critical care situation.

If stabilizing a patient with psychiatric problems would include protecting the airway, repairing a slashed wrist or throat, or gastric lavage for poisoning or overdose, those would likely support the critical nature of the presentation. Need for immediate physical and chemical restraints would also be further supportive of potential imminent deterioration in the patient’s condition.