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Critical Care Ins and Outs Through FAQs

Updated: Oct 1, 2023

Every day we get calls from clients asking questions about critical care. Because this is an ongoing hot topic, it is important for physicians and coders alike to understand the ins and outs of critical care coding and billing.

Q: Can I bill a critical care code for any patient that I see in the ICU?

A: No, critical care codes are to be reserved and reported for patients that are critically ill. In order to determine if your patient is critically ill, ask yourself if treatment was withheld to this patient on an emergent basis, would a life-threatening deterioration occur? If the answer is yes, then it would be critical care.

  • Include organ system failure/life threatening deterioration

  • Treatment involved

  • Time spent in critical care management

Q: Can I report a subsequent visit and critical care services/treatment on the same day?

A: Yes, you may have rounded on a patient earlier in the day who was stable and then throughout the course of the day the patient’s status deteriorates and requires critical care treatment. Both services are billable.

Q: If I transfer the patient out of the ICU to a step-down unit are my services billable?

A: Yes, because you are transferring the patient to a step-down unit the patient is no longer considered critically ill, you would report your service using codes from subsequent service codes 99231-99233 depending on the documentation elements of the medical decision making. (a medically appropriate history and physical examination should be documented as well)

Q: If I do not meet the time threshold for critical care services 30-minutes, is my critical care services still billable?

A: Yes. If you do not meet the 30-minute time threshold, you would report your services using the appropriate subsequent (99231-99233) E/M code for his/her time.

Q: Can I utilize the nurse practitioner documentation to support my critical care documentation?

A: Both practitioners must document the services that they provided to the patient meeting critical care requirements; life threatening deterioration/organ system failure, interventions performed, and time spent in critical care management.

Q: How do I justify to an insurance carrier that my patient meets CMS criteria for critical care management?

A: In order to do this, explain all of the following:

  • How the patient was critically ill

  • What you did for the patient

  • The cumulative critical care time spent on direct and indirect patient care

Try documenting the following points, if applicable:

  • Severity of illness and potential for decompensation

  • Vital signs (hypotension, hypoxia, etc) and how these changed through the case

  • Tests performed and your interpretation of the results

  • Treatments provided, including: supplemental oxygen, IV fluids, medications, blood transfusions, burn/wound care

  • Procedures performed

  • Re-assessments of the patient’s status and response to interventions

  • Conversations with EMS, the patient, the patient’s family or surrogate decision makers, nursing home personnel, consultants, and admitting teams

  • Information retrieved by chart review and how this impacted patient care

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