Beware: CPT, CMS differ on 'family discussion' parameters. Q. What Must I Carve Out of Critical Care Time? Be careful when considering critical care minutes. Many services that you might think are part of the 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) package are actually separately billable procedures, pointed out Caral Edelberg, CPC, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La., during her recent presentation at The Coding Institute's multi-specialty conference in Orlando, Fla. (www.codinginstitute.com). "The critical care clock stops," explained Edelberg, "during separately billable procedures such as CPR, endotracheal intubation, chest tube/central line insertion and ultrasound interpretation." Critical care time also excludes the following: • teaching time aside from the actual care • most time spent speaking with authorities, family members, or caregivers that do not directly bear on the patient's medical care. (There are exceptions to this rule; check FAQ 2 for more info.) Also, don't just use total time the patient spends in the emergency department (ED) or intensive care unit (ICU), because not all of it is active critical care time. Example: Q. What's Included in Critical Care Time? Most other services that the physician provides to the critically ill patient are part of the 99291 package, including interpretation of cardiac output measurements,chest x-rays, pulse oximetry, blood gasses, and information data stored in computers (such as ECGs, blood pressures, and hematologic data); gastric intubation; temporary transcutaneous pacing; ventilator management; and some vascular access procedures (though not central line codes or arterial line insertion). Exception: "[Critical care] time does not include time speaking with family/authorities -- unless obtaining history or discussing options, such as advanced directive matters," Edelberg noted. CPT and Medicare have specific commentary regarding what types of circumstances and conversations outside of direct patient care may count toward critical care time: Medicare rules: CPT rules: