Pulmonology Coding Alert

Question: My physician documented that he performed critical care services for a patient whom he discharged from the ED. Is that possible? Would patients who need critical care services improve enough to go home instead of into the hospital?

Iowa Subscriber

Answer: This sort of situation is highly unusual. However, just because a patient requires critical care services does not mean he will not improve enough to warrant discharge. The key point to your question is, "Does the documentation clearly support the critical nature of the patient's illness and the services provided?" Critical care is defined as "the direct delivery by a physician 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.

Critical care involves high-complexity decision making to assess, manipulate, and support vital system functions 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 system failure include central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life-threatening situations when these elements are not present. Providing medical care to a critically ill, injured, or postoperative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care.

Example: A patient suffering from an anaphylactic reaction due to a drug allergy may present in the ED, receive critical care from the ED physician, and, once stabilized, safely return home.

As long as your physician's work meets the definition of critical care, he is not required to admit the patient to the hospital to report 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]).

Remember: Don't assume a service is critical care based on a final outcome. Whether a service meets critical care requirements depends on the treatment, the level of care performed, the seriousness of the patient's condition, the time spent providing critical care, and your physician's documentation and notes.