Medicare Compliance & Reimbursement

Question: Does the emergency department (ED) physician need to complete all the HPI, ROS, history, and exam elements in order to bill for critical care time?

Answer: No, he doesn’t. You can bill critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (…each additional 30 minutes…) without the elements that are required for the emergency department evaluation and management (E/M) 99281-99285 codes.

Unlike the emergency department evaluation and management codes (99281-99285), with which the documentation needs to satisfy either CPT^® or Medicare requirements, the rules are less stringent for critical care codes. Although the patient’s chart should certainly reflect the nature of their condition and the clinical course the physician chose, there is no specific requirement regarding the amount of documentation related to the history of present illness (HPI) and review of systems (ROS) elements for critical care.

But don’t forget, unlike the ED E/M codes, critical care codes are time-based. The most important elements to look for in the physician’s documentation include: that the patient satisfies the definition of critically ill, and that the doctor delivered a minimum threshold of 30 or more minutes of critical care.

Remember: Don’t include any time the doctor spent on separately billable procedures in the critical care minutes.