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Medicare Compliance & Reimbursement

CRITICAL CARE Here's What You Need When Reporting Critical Care -- And What You Don't

Published on Mon Jun 11, 2007

Dodge critical care mistakes by dispelling 2 myths.

A physician can provide critical care just about anywhere he meets the patient and provides the service. If you meet two important requirements in the time and documentation departments, your claim will be successful even if the physician is not in the emergency department or other "critical care area."

Important: A patient who receives critical care "does not actually have to be in a critical care setting," says Jacquelyn Dodge, receptionist/coder at Eric A. Wingerson, DO, in Idaho Falls, ID.

Bottom line: Keep good records, and most payers will reimburse for 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]).

Myth #1: You Can Provide Critical Care Only In ED

If you think that your physician has to be in an emergency department (ED) or other "critical care area," you may be missing out on well-deserved reimbursement. 

In other words, no matter the setting, critical care is based on time only spent for the critically ill or critically injured patient, meaning there is a high probability of imminent or life-threatening deterioration of the patient's condition, experts say.

Resource: To get the whole definition of critical care, you should check out the CMS manual at the following URL: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

Although most critical care occurs in an emergency department or other "critical care area," Medicare pays for critical care provided in any location if you meet the guidelines. Conversely, a patient's presence in an intensive or critical care unit doesn't necessarily qualify as a critical care situation.

Myth #2: Documentation Is Secondary To Setting

Although the critical care may have occurred in a non-traditional setting, the service is still a viable critical care claim--as long as you meet documentation requirements, experts say.

"Whether a service meets critical care requirements depends on treatment, level of care performed, gravity of the patient's condition, and the physician's documentation and notes," says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City. In critical care, setting is secondary to documentation.

Heed this advice: To lock up reimbursement for your critical care claims, check out this short list of tips on documentation:

1. Note a start and stop time for the critical care services.

Also, document time spent on all care management services provided in that time. If the cardiologist provided critical care and another service in the same session, be sure to explain how much time the physician spent providing each service and only bill those minutes dedicated to critical care as critical care time, specifically excluding minutes spent rendering separately billable procedures.

2. Give details about all the services the physician provides.

These services would include the usual E/M components. Other services that may (or may not) be part of a carrier's critical care package include:

• interpretation of cardiac output studies

• chest x-rays

• blood gases

• electrocardiograms

• blood pressures

• ventilation management

• vascular access procedures.

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