Are your critical-care claims at risk for denial or repayment upon review? Several payors have identified increased potential for critical-care reporting discrepancies, which has resulted in targeted prepayment reviews of this code.1 Some payors have implemented 100% review when critical care is reported in settings other than inpatient hospitals, outpatient hospitals, or emergency departments.2 To ensure a successful outcome, make sure the documentation meets the basic principles of the critical-care guidelines.
Defining Critical Illness/Injury
CPT and the Centers for Medicare & Medicaid Services (CMS) define “critical illness or injury” as a condition 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 (e.g. central-nervous-system failure; circulatory failure; shock; renal, hepatic, metabolic, and/or respiratory failure).3 The provider’s time must be solely directed toward the critically ill patient. Highly complex decision-making and interventions of high intensity are required to prevent the patient’s inevitable decline if left untreated. Payment may be made for critical-care services provided in any reasonable location, as long as the care provided meets the definition of critical care. Critical-care services cannot be reported for a patient who is not critically ill but happens to be in a critical-care unit, or when a particular physician is only treating one of the patient’s conditions that is not considered the critical illness.4
Examples of patients who may not satisfy Medicare medical-necessity criteria, do not meet critical-care criteria, or who do not have a critical-care illness or injury and therefore are not eligible for critical-care payment:
- Patients admitted to a critical-care unit because no other hospital beds were available;
- Patients admitted to a critical-care unit for close nursing observation and/or frequent monitoring of vital signs (e.g. drug toxicity or overdose);
- Patients admitted to a critical-care unit because hospital rules require certain treatments (e.g. insulin infusions) to be administered in the critical-care unit; and
- Care of only a chronic illness in the absence of caring for a critical illness (e.g. daily management of a chronic ventilator patient; management of or care related to dialysis for an ESRD).
These circumstances would require using subsequent hospital care codes (99231-99233), initial hospital care codes (99221-99223), or hospital consultation codes (99251-99255) when applicable.3,5
Because critical-care time is a cumulative service, providers keep track of their total time throughout a single calendar day. For each date and encounter entry, the physician’s progress notes shall document the total time that critical-care services were provided (e.g. 45 minutes).4 Some payors impose the notation of “start-and-stop time” per encounter (e.g. 10 to 10:45 a.m.).
Code This Case
Consider the following scenario: A hospitalist admits a 75-year-old patient to the ICU with acute respiratory failure. He spends 45 minutes in critical-care time. The patient’s family arrives soon thereafter to discuss the patient’s condition with a second hospitalist. The discussion lasts an additional 20 minutes, and the decision regarding the patient’s DNR status is made.
Family meetings must take place at the bedside or on the patient’s unit/floor. The patient must participate, unless they are medically unable or clinically incompetent to participate. A notation in the chart should indicate the patient’s inability to participate and the reason. Meeting time can only involve obtaining a medical history and/or discussing treatment options or the limitations of treatment. The conversation must bear directly on patient management.5,6 Meetings that take place for family grief counseling (90846, 90847, 90849) are not included in critical-care time and cannot be billed separately.