• Angel Callaway, CPC, CPB

Is It Really Critical Care?


Do you struggle with billing critical care evaluation and management services? Critical care can be confusing. Understanding the definition of critical care is the first step to billing this service correctly.

  • To bill for critical care the patient must have a critical illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration of the patient’s condition.

  • A patient’s care is not automatically critical care services just because the patient is in ICU/CCU. Critical care codes represent the intensity of care that is greater than a standard E&M code.

  • The care must involve highly complex decision making that is necessary to assess, manipulate and support vital system function to treat vital organ failure (shock, renal/hepatic/respiratory failure, etc.) and or prevent the patient’s inevitable decline if left untreated.

The following elements are required to assign a critical care code:

  • Patient must be critically ill or injured.

  • One or more vital organ system must be acutely impaired with high probability of imminent or life-threatening deterioration.

  • Vital organ system includes brain, heart, kidney, liver, and lungs.

  • Prevention of further life-threatening deterioration must be done.

  • CMS states both treatment of vital organs and further prevention of deterioration must be done to qualify for critical care.

All critical care services rendered on a single day by the provider or a provider of the same specialty will be reported with a single code. Critical care by a provider of different specialty with be reported with the critical care codes. Other E/M services may be provided to the same patient on the same day.


The following services are included in critical care when reported by the provider of critical care.

  • Cardiac output measures-93561,93562

  • Chest x-ray-71045,71046

  • Pulse ox-94760,94761,94762

  • Blood gases

  • ECG

  • Blood pressure

  • Hematological data

  • Gastric intubation-43752,43753

  • Temporary transcutaneous pacing-92953

  • Ventilatory management-94002-94004, 94660,94662

  • Vascular access procedures-36000, 36410,36415, 36591, 36600

Any services not included in this list should be reported separately.


Time spent with the patient in critical care must be documented in the chart. The time must be devoted to that patient only. Critical care can be billed in outpatient settings (e.g., emergency department, observation) the location of critical care is not a determining factor for code selection.


References:

Center for Medicare and Medicaid Services, MLN Matters MM5993, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5993.pdf.

American Medical Association, Current Procedural Terminology 2019, Evaluation and Management Services Guidelines, Pg. 23-25, 44-47.

American Medical Association, CPT Assistant, Critical Care Services Revisited, August 2019 pg. 8, 12.



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