Critical Care
Critical care means that a doctor or a skilled healthcare provider is giving urgent medical attention to a very sick or seriously injured patient, where if the critical care is not provided then the patient may further deterioration of the condition.
To bill the critical care following are requirements:
Critical condition(s)
Aggressive Intervention
Time excluding other billable procedures (minimum 30 minutes is required to bill the critical care)
A critical illness or injury severely affects one or more important organ systems, putting the patient at high risk of immediate, life-threatening deterioration.
Conditions that could call for critical care include (but are not limited to):
Central nervous system failure
Circulatory failure
Shock
Renal hepatic, metabolic and/or respiratory failure
Overwhelming infection
Tips:
Medicare rules state that only one doctor can report critical care for a patient on a single day, even if multiple doctors are involved in the patient's care. Any other doctors who provided care should use the subsequent hospital care codes (99231-99233) instead of critical care codes.
Let's say a doctor in the emergency room is taking care of a patient in shock. After 25 minutes, the patient becomes more stable and is no longer in immediate life-threatening danger.
In this situation, since the critical care lasted less than 30 minutes, you should use a regular emergency room visit code, not the special 99291 code for critical care.
The time a doctor spends on critical care doesn't have to be all at once; it can be in separate parts. You just add up all the time spent on critical care for a specific date to get the total.
For example, if the doctor provides one hour of critical care to stabilize the patient, and then later on the same day, the patient's condition gets worse, and the doctor spends another hour, you can use code 99291 for the first hour and code 99292 (which means two additional hours) for the second hour, even though they weren't continuous.
Bundle procedure into Critical care:
For healthcare professionals reporting critical care services, the following services are considered part of critical care when performed by the physician(s) during the critical care period:
Interpretation of cardiac output measurements (93598).
Interpretation of chest X-rays (71045, 71046).
Pulse oximetry monitoring and interpretation (94760, 94761, 94762).
Analysis of blood gases.
Collection and interpretation of physiologic data, such as ECGs (electrocardiograms), blood pressure readings, and hematologic data.
Gastric intubation procedures (43752, 43753).
Temporary transcutaneous pacing (92953).
Ventilatory management, including services identified by codes 94002, 94003, 94004, 94660, and 94662.
Vascular access procedures, which are covered by codes 36000, 36410, 36415, 36591, and 36600.
Any other services performed during critical care that are not listed above should be reported separately. Healthcare facilities may also report these services separately if necessary.
Time:
The doctor has to spend at least 30 minutes excluding other billable procedures giving important medical care to a patient for it to be considered critical care, as per the rules. If the care takes less than 30 minutes, the doctor will use a different code for the visit, following the guidelines.
Aggressive Intervention:
Critical care involves making complex decisions to evaluate, control, and support these vital systems, either to treat a single or multiple organ failure or to prevent further life-threatening deterioration. Critical care often involves monitoring various physiological indicators and using advanced technologies, it can also be given in emergency situations where these tools aren't available. Critical care may continue over multiple days, even if the treatment doesn't change, as long as the patient's condition still demands the same level of attention.
Critical Care and Other Same-Day Evaluation and Management (E/M) Visits :
Scenario 1:
When an E/M visit is performed in the morning and critical care is provided later in the evening, both services can be billed.
This is because the E/M visit occurred before the patient required critical care, the services are medically necessary, and they are separate and distinct with no duplicative elements.
Use modifier -25 on the E/M claim to indicate it is a significant, separately identifiable service from the critical care.
Scenario 2:
When critical care is provided in the morning and an E/M visit is performed later in the evening, only the critical care services should be billed.
This is because the patient was already under critical care in the morning, and any subsequent E/M visit on the same day is considered part of the critical care services and not separately billable.
In this scenario, billing for both services is not allowed due to the overlapping nature of the care provided.