Medicare Compliance & Reimbursement

Know what constitutes a 'critical illness or injury.' Question: I've experienced some denials on critical care codes for patients I considered to be seriously ill. Can you review the parameters for coding critical care? Answer: According to CPT, "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." "Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ systemfailure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure." You'll have to prove that the patient met the above criteria before considering 99291 (Critical care, evaluation and management of the critically ill [...]