Critical care documentation

Background

• Delivery of critical care is common in the ED setting
• Critical care billing (CPT 99291/99292) typically generates higher RVUs than standard E/M coding (see Billing)
• Multiple components must be satisfied and appropriately documented in the medical record when delivering critical care in the ED
• Critical care and E/M services cannot be billed for the same time period; however, an E/M code may be billed for the initial evaluation if the patient subsequently becomes critical
• Studies suggest that ED physicians significantly under-bill for critical care services

Elements of Critical Care Time

• Critical illness or injury = illness or injury that 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 services = direct medical care that involves high complexity decision making to assess, manipulate, and support vital organ system failure
• CMS additionally mandates that for Medicare patients, "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration in the patient's condition"

Time Calculation

• Time spent in critical care activities must exceed 30 minutes in order to bill for critical care
• CPT 99291 = first 30-74 minutes of critical care time (8.19 RVUs)
• CPT 99292 = each additional block of up to 30 minutes beyond the first 74 minutes
• Must document either a specific time or statement (e.g., "in excess of 30 minutes")
• Time does not have to be continuous
• Includes: direct patient care at bedside, reviewing test results, discussing case with consultants or family, documenting in chart
• Excludes all separately billable procedures:
  • Central line placement
  • Endotracheal intubation
  • Chest tube placement
  • CPR
  • Transvenous pacemaker placement
  • Lumbar puncture

Sample Documentation

Critical Care Procedure Note

Authorized and Performed by: [MD Name]

Total critical care time: Approximately ___ minutes

Due to a high probability of clinically significant, life-threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient's response to treatment; frequent reassessment; and, discussions with other providers.

This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time.

Please see MDM section and the rest of the note for further information on patient assessment and treatment.

Common Clinical Conditions Consistent with Critical Care

• Must be first diagnosis in the chart

Category	Conditions
Cardiovascular	Acute coronary syndrome with progressive pain management; unstable angina; Cardiac arrest; Atrial fibrillation with tachycardia not responding immediately to treatment; rapid heart rate requiring IV therapies; shock (any type)
Respiratory	Status asthmaticus; severe COPD exacerbation; Pulmonary embolism; Pneumothorax with respiratory distress; Pulmonary edema; Respiratory failure
Neurological	Coma/unresponsive (unknown cause); Status epilepticus; acute Stroke with paralysis; Subarachnoid hemorrhage; Subdural hematoma; severe Head injury
Metabolic / Infectious	Sepsis/septicemia with hypotensive management; DKA; Hyperkalemia with aggressive management; acidosis with aggressive management; severe dehydration with metabolic changes
Trauma	Altered consciousness with life/limb threatened; severe bleeding requiring transfusion; unstable vital signs
Other	Active bleed requiring OR; anaphylactic shock; Overdose with acute vital sign changes; suicidal ideation requiring chemical/physical restraints

Common Pitfalls

• Not documenting a specific critical care time (must state minutes)
• Failing to state that time excludes separately billable procedures
• Not documenting the clinical rationale for why the patient is critically ill
• Forgetting to document critical care when managing multiple critical patients simultaneously (each patient's time is counted separately)
• Under-billing: many ED encounters qualify for critical care billing but are coded at a lower level

See Also

• Documentation for emergency physicians
• Billing
• Observation documentation

Documentation Pages

• General
  • Documentation for emergency physicians
  • Billing
• Components of the Medical Record
  • Review of systems documentation
  • Physical exam documentation
  • Differential diagnosis documentation
  • MDM for different chief complaints
  • MDM for different chief complaints (peds)
• Procedure and Reexamination
  • Procedure sample documentation
  • Reexamination sample documentation
• Special Documentation
  • Critical care documentation
  • Observation documentation
  • Against medical advice
  • Discharge documentation
  • Death documentation
  • Informed consent documentation
• Reference
  • Ophthalmology abbreviations

External Links

• ACEP Critical Care FAQ