July 19th, 2019
Critical care services remain to not only be an area of confusion for providers, coders, and auditors, but also a constant target for the carriers for audit. We can sit back and look at critical care and think of all of the ways the code descriptor and/or use could be better defined to prevent misuse - but at the end of the day, the rules are the rules. So, we will continue to have a back and forth between auditor/coder and provider as to what truly constitutes critical care. I hope to try and help give some good tips and qualifiers to help you in making these decisions and to aide in teaching your providers.
- Organ system failure
- Details of the critical care service provided
- Total time of the critical care encounter
AMA CPT Guidelines has a statement that pretty well sums up what is needed to answer why
It's common to want rules and guidance to know if the coding decision being made is correct, but face it - most of what we review
The next portion of this statement indicates that these high-level decisions are being made in an effort to assess, manipulate, and support vital system functions.
* Assess would indicate that high complexity was involved in assessing the needed interventions for the patient during this encounter. The examination, review of labs, testing, imaging, and all of the physical work needed to provide critical care.
* Manipulate infers that high complexity decisions were used when creating the active treatment plan for stabilizing the patient. Unfortunately, when a provider is trying to convey manipulation of high complexity in the documentation, this would best be communicated by the provider by documenting their thought process regarding the critical care intervention.
* Support of vital system function indicates our provider is making
All of these work together to help define the medical necessity behind the need to provide
When referring to E&M code selection, CGS Medicare states that medical necessity is a culmination of the provider's mental and physical work involved in treating the patient. However, the documentation must show that mental and physical
Providers, unfortunately, must embrace that documentation is their testimony to the actual events provided to the patient on that date of service, and it is required that they also testify as to why those services were provided.
It takes both pieces to validate not just critical care, but all services provided to patients.