Presenters: Christine Mikesell, MD, Yiling Katharine Chang, MD, and Maria Skoczylas, MD
The 2023 Centers for Medicare & Medicaid Services changes to inpatient evaluation and management coding have prompted institutions and practitioners to re-evaluate their billing practices, as both under-billing and over-billing can result in an audit. As practices review their billing, it is important to remember that hospitalists can use critical care codes outside of an intensive care setting if the diagnosis, intervention, and documentation meet the criteria. While critical care codes may not be location-dependent, they may be weight (newborn) or age (pediatric) dependent in pediatric medicine.
As defined by the American Medical Association CPT 2023 Professional Edition, “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. Critical care involves 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.”1 Critical care typically involves the interpretation of multiple physiologic parameters or the application of advanced technology; however, critical care may be provided in life-threatening situations without these elements.
The presenters at PHM 2023 suggest ensuring the presence of three key elements before reporting critical care:
- At least one vital organ system is impaired
- There is a high probability of imminent, life-threatening deterioration without intervention on an urgent basis
- The practitioner intervened to manage the organ failure and prevent further deterioration of the patient’s condition
The illness or injury and the treatment must meet the critical care level.
The presenters spent years working with the billing and compliance departments at their institution and noted their breakthrough came in the establishment of a hospital-wide definition of respiratory failure. From their definition of acute, chronic, or acute-on-chronic respiratory failure, they built standardized attestations that included diagnosis and treatment that would support billing of critical care. Further critical care can be billed if a patient is in organ failure with documentation of high-level medical decision making, if the condition is worsening and care is increasing, or if treatment is preventing deterioration. Hospital medicine providers may also bill critical care during rapid-response or sepsis-response events if the treatment and outcome meet the criteria.
For patients older than five years of age, time-based critical care codes are used. These codes require a minimum of 30 minutes and documentation of time spent. If multiple encounters are documented in a single day, the billing is based on the accumulation of time spent during the day. For patients younger than five years old, age-based critical care codes are used, which are not based on time, but documentation of time spent is still expected. Remember that time spent in critical care should be the attending physician’s time and that documentation of the patient’s condition should match the care that is billed.
- Time-based and daily critical care codes can be used by hospitalists outside of an intensive care unit.
- Critical care service billing requires three key elements.
- It is recommended to work with your local compliance department to develop billing standards for your institution.
Dr. Baucher is a pediatric hospitalist at Akron Children’s Hospital in Akron, Ohio. She currently splits her time between nocturnist work at the children’s hospital and neonatal hospital medicine at Wooster Community Hospital in Wooster, Ohio, where she also serves as the site director and chair of the department of pediatrics.
- 2023 CPT Professional Edition, American Medical Association, Oct 28, 2022. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf