Q: Can we bill for critical care services when spending extra time with patients who are very ill?
A: It is rare that you would perform billable critical care services in the urgent care setting. According to the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA), critical care is defined as the direct delivery by a physician(s) 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. They further define critical care as involving high-complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.
A few examples of vital organ system failure include:
- Central nervous system failure
- Circulatory failure
- Renal failure
- Hepatic failure
- Metabolic failure (eg, hypothermia, acidosis, coagulopathy)
- Respiratory failure
Critical care services must be medically necessary and reasonable, while also meeting all criteria noted above. If critical care is provided in a moment of crisis or the provider is called to the patient’s bedside emergently, this is not considered as providing critical care. The key factor is the provider’s deliverance of the treatment and management of the patient’s condition based on the threat of imminent deterioration (ie, the patient is critically ill or injured at the time of the visit). Therefore, providing medical care to a critically ill patient should not be automatically deemed to be a critical care service even if the patient is critically ill or injured.
Services that do qualify as critical care when performed in the outpatient or office setting during the critical period by the provider of the critical care are:
- Interpretation of cardiac output measurements (Current Procedural Terminology [CPT] codes 93561, 96562)
- Chest x-rays, professional component (CPT codes 71010, 71015, 71020)
- Pulse oximetry (CPT codes 94760, 94761, 94762)
- Blood gases, and analysis of clinical data stored in computers (eg, ECGs, blood pressures, hematologic data [CPT code 99090])
- Gastric intubation (CPT codes 43752, 73753)
- Temporary transcutaneous pacing (CPT code 92953)
- Ventilator management (CPT codes 94002-94004, 94660, 94662)
- Vascular access procedures (CPT codes 36000, 36410, 36415, 36591, 36600)
Critical care is a time-based service where the provider must document the total time spent for each date and encounter in the patient’s medical record.
The time spent providing critical care services to a critically ill or critically injured patient does not have to be face-to-face, and does not have to be continuous. Time can be reported when the provider is engaged in work directly related to the patient’s care on the floor or unit, as long as the provider is immediately available for the patient. For example, time spent reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff, or documenting critical care services in the medical record can be reported, as long as these are performed on the unit or floor where the patient is located. Also, when the patient is unable or lacks capacity to participate in discussions, time spent with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment can be reported, provided the discussion bears directly on the management of the patient and, again, is performed on the unit or floor where the patient is located. Time spent transporting a critically ill or critically injured patient from one facility to another can also be counted toward the total time.
For any given period of time spent providing critical care services, the provider must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.
Any time spent on evaluation and management (E/M) services performed on the same patient, on the same day as critical care services prior to or after the patient becoming critically ill or injured, should not be counted toward critical care time. CMS advises that providers billing for an E/M service with critical care service(s) on the same date of service must submit documentation to support the claim. Although it is rarely appropriate to use time to determine the level of E/M in the urgent care setting, E/M services codes already reflect an element of time.
For example, the AMA has assigned a typical time of 40 minutes to a level 5 visit for an established patient in an office (99215). Thus, if the physician spends 60 minutes caring for a patient who requires critical care services, the first 40 minutes count toward the E/M (99215), and the next 20 minutes toward critical care services. Since the minimum threshold to use 99291 (“Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes”) is 30 minutes, this code would not apply. Because it would be extremely rare for a clinician to spend more than 60 minutes providing critical care in the urgent care setting, critical care codes very rarely apply to services rendered in an urgent care.
Critical care CPT codes for reporting are 99291, “Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes” as noted above and 99292, “Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).”
CPT code 99292 must be used in conjunction with 99291. See Table 1 for the calculation of time and coding.