Will Your Critical Care Services Pass An Audit?

by  Aimee Wilcox, CPMA, CCS-P, CST, MA, MT
February 8th, 2022

What Are Critical Care Services

According to Noridian, a Medicare Administrative Contractor (MAC):

CMS defines critical care as “the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient” and also defines a critical illness or injury as one that “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.” We have included several examples of critical care situations, provided by CMS.

While this basic definition of critical care services (CCS) is similar in nature to other CMS MACs, commercial payers, and the CPT codebook guidelines, it is important to know the exact billing criteria for each payer. When billing any procedure or service, it is vital that the physician or other QHP has documented the details of the service in a manner that supports medical necessity and the code description. 

Who Qualifies for CC Services? 

Just because a patient is located in a critical or intensive care unit does not mean the service automatically qualifies as critical care. According to Novitas, there are two criteria that must be met in order to report critical care services (99291, 99292) instead of an E/M service:

Clinical condition criterion - There is a high probability of sudden, clinically significant, or life threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently.

Treatment criterion - Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or 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.

Patients admitted to the hospital, more often than not, require high complexity decision making. However, patients receiving critical care services are those that are hospitalized and their condition is so complex or risky that they have a high probability of dying without immediate and advanced medical care. Critical care services require the provider be qualified to evaluate and treat for the condition and the ability to intervene immediately. 

Patients who have been admitted to an intensive or critical care unit (ICU/CCU) do not automatically qualify for critical care services (CCS). Each patient encounter must be evaluated to determine whether the patient’s status on that date continues to qualify for CCS or should be reported as subsequent hospital E/M services. As a matter of fact, while most patients receiving critical care services are physically located in the hospital setting, it is also possible for them to receive critical care services in the office, urgent care, ambulatory surgery center (ASC), or elsewhere. There is no “designated room” set aside where critical care services have to  be provided but the criteria must be met for patient qualifications and provider work/documentation.

Who Can Provide Critical Care Services? 

Providers such as MDs, DOs, NPs, PAs, and residents may perform critical care services, if qualified by licensure and scope of practice to do so. While a resident may perform critical care services, they can only be billed IF the attending physician (teaching physician) was present the entire time and only the time spent by the attending physician is counted. No time spent by the resident performing critical care services may be counted for billing purposes.

Critical Care Services are Time-Based

The code description identifies the time requirement for each code: 

Code

Unit

Time

99291

1

30-74 minutes

99292 (+)

1

each additional 30 minutes

The following bullets delineate the specific time-based reporting CPT guidance: 

Critical Care Coding Scenarios

Auditing Critical Care Services

Critical care services involve high complexity medical 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. The patient encounter notes must support services that involve high complexity decision making and treatment of a critical condition and should not be supported by cloned, templated, or copied and pasted notes with no updates to show what has changed since the last encounter. 

When reviewing critical care service notes, it is best to disregard cloned or copied/pasted documentation that does not clearly identify applicability to the current encounter. Look for documentation that shows what is new and differs from the last critical care encounter. Patients in critical care who have become stable and will be moved out of critical care are reported with subsequent hospital E/M service codes. Critical care, day after day, should not occur without justification.


Disclaimer: The above article is the opinion of the author(s) and should not be interpreted by providers/payers as official guidance. For any questions about the content of this article, please contact the author(s).

About the Author: Aimee Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. She believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.

Will Your Critical Care Services Pass An Audit?. (2022, February 8). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/will-your-critical-care-services-pass-an-audit-36972.html

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