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General Surgery Coding Alert

You Be the Coder:

E/M: Service Drives Critical Care

Published on Mon Apr 18, 2011

Question:

After a patient with chest pain "coded" in the ER and was admitted to ICU, our surgeon saw the patient for a surgical consult. The patient was lethargic and a poor historian, so most of his information came from prior medical records. Our surgeon did not document time. Can we charge for critical care since the patient was in the ICU?

North Carolina Subscriber

Answer:

No -- you can't bill critical care simply because the place of service is the intensive care unit (ICU).

The service you describe would be an inpatient consultation, such as 99251-99255 (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 99221-99223 (Initial hospital care ...)

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 something like shock)

The physician must document at least 30 minutes of time spent directly with the patient or on the floor

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 (including surgery) to create an overall care plan. That's why you don't usually bill critical care codes in general surgery practices.

On the other hand: Some surgeons do provide critical care, such as for patients with multiple trauma or organ transplant. Then, you'd need to document the services your surgeon provides from the criteria listed above.

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