Inpatient Facility Coding & Compliance Alert

Question: We've heard that the patient code status (DNR, DNI, full code) is one of the items to take into account when deciding whether physician services are considered critical care or not. Is that true?

Washington Subscriber

Answer: The patient's code status doesn't dictate whether the service can be considered critical care -- that's determined by the care that's given.

Remember the CPT® guidelines for critical care: "Critical care is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition ..." CPT® includes thorough instructions for reporting critical care services with codes 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity) and +99222 (... A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity).

Exception: If the physician is providing comfort measures for a patient who is DNR and truly at the end of life, then he is not providing critical care. For example, a patient is admitted in critical condition because of pneumonia and other complications. Her hospital record from previous stays lists her as DNR beyond standard medical care. A few days later it is evident that she won't recover from her critical state without more heroic measures, which goes against her documented wishes. The healthcare team shifts from critical care measures to providing end-of-life comfort measures. Her DNR status remains the same throughout the stay, but you should only report critical care codes for the first few days before transitioning to end-of-life care.

Remember: Both the physician and hospital should be documenting that critical care was provided, not just listing the services. That documentation should include the phrase "critical care."