Pulmonology Coding Alert

Insurers pay strict attention to the definition of critical care when calculating reimbursement, so you'll need to keep pace by cracking open the CPT manual and studying up.

Critical care is defined in the 2003 CPT manual as "the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient." A critical illness impairs one or more vital organs or systems such that the patient's survival is in jeopardy.

Critical care is also provided if there is a high probability of "imminent or life-threatening deterioration in the patient's condition." Vital signs may be stable and the patient still be considered critically ill. According to Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm based in Lansdale, Pa., that specializes in financial and healthcare management with a focus on physician compliance, coding, billing and reimbursement, there are several important points to remember: Critical care requires direct personal supervision, and the physician cannot provide services to another patient during this time. Critical care involves decision-making of high complexity to assess, manipulate and support vital system function. Although it is often the case, critical care does not have to involve the interpretation of multiple physiologic parameters and the application of advanced technology. Critical care services are usually but not always given in a designated critical care area, such as an ICU or RCU, and services for those in these areas who are not critically ill use the proper E/M codes only. The physician should not report critical care codes just because the patient is in a critical care area. For example, vital signs may be stable, but a doctor needs constantly to watch a person whose blood pressure if 90/50. Proper documentation must be present to bill these services as critical care.