Gastroenterology Coding Alert

Question: After a patient with severe abdominal pain and hemoptysis in the ER was admitted to the ICU, our gastroenterologist saw the patient for a consult. The patient was lethargic and a poor historian, so most of his information came from prior medical records. Our doctor did not document time. Can we charge for critical care since the patient was in the ICU?

California Subscriber

Answer: No, you cannot bill critical care (99291-99292, Critical care, evaluation and management of the critically ill or critically injured patient ...) simply because the place of service is the intensive care unit (ICU).

The service you describe would be an inpatient consultation, such as 99253 (Inpatient consultation for a new or established patient ...). For Medicare or other payers not accepting consultation codes, this would constitute an initial hospital care code such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...).

Critical distinction: Critical care is not location-based; rather, it describes a specific kind of care. You must meet the following criteria to bill for critical care:

• The patient must have a critical illness (usually defined as a critical organ system failure or a shock-like syndrome)
  
• The physician must document at least 30 minutes of time spent directly with the patient or on the floor (hospital unit) limited only for that patient
  
• The physician must document highly complex decision making to assess, manipulate, and support vital system function(s) to treat the critical illness or prevent further deterioration of the patient’s condition.
  
• Typically, the physician providing critical care monitors the patient for an extended time and obtains opinions and advice from multiple specialties to create an overall care plan.