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Reporting adult critical care can be tricky not only because of the coding but also because of the rules and regulations that go with it. Many questions arise when reporting critical care services in addition to other hospital services. You would think it would be fairly easy since there are only two codes for adult critical care—99291 for the first 30 to 74 minutes and 99292 for each additional 30 minutes in a calendar day. But questions repeatedly arise as to when a practitioner is practicing critical care.
1.How is critical care defined?
2. How do we document time?
3. What are the rules for teaching physicians and billing for critical care?
4. Do I need a modifier when performing a bedside procedure the same day I provide critical care to a patient? What modifier should I use?
Critical Care Defined
According to the American Medical Association (AMA) Current Procedural Terminology (CPT) 2017, “Critical care is the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient. 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 must be medically necessary and reasonable, according to the Centers for Medicare and Medicaid Services (CMS). But what does that mean to the practitioner? When a patient has the potential for further deterioration, is that critical care? What about the patient who is on a ventilator but is stable? Does this qualify as critical care? According to CMS Publication 100-4, chapter 12, critical care is defined as service that encompass both treatment of “vital organ failure” and “prevention of further life threatening deterioration of the patient’s condition.”2 A patient whom a clinician is providing chronic ventilator management may not be considered critical unless the patient meets the critical care definition even if the patient is being managed in the critical care unit. A patient who had surgery and is placed in critical care for constant observation might not meet the definition if there is no potential for life-threatening deterioration. So, understanding what constitutes critical care is vital in reporting the services accurately. Examples that meet the criteria for critical care are: