番茄社区

The practice of medicine, as a business, is a challenging model. You have minimal control over your prices, no ability to negotiate with your biggest payers (the governmental ones, that is), and limited leverage to contract with commercial payers. In our specialty, you also know that a certain significant but unpredictable fraction of your patients will not be paying you at all, and you have to staff to an expected patient volume, but you have no real ability to control your volume. Compensation for services from all payers is perpetually squeezed downward, and given the narrow focus of our specialty, it is difficult to diversify the business model.

So, if you want to run a profitable and successful practice, you need to focus on the internal efficiencies to maximize your revenue. The universal inefficiency in EM practices is physician documentation; this inefficiency is, of course, also an opportunity to improve, and thereby increase your revenue. For most practices, 85% of revenue can be accounted for with only seven codes: 9928x and 9929x in coding jargon, commonly referred to as the Evaluation and Management (E/M) codes and Critical Care (CC). A lot of attention is paid to the E/M coding requirements, as they are onerous and failure to comply will absolutely sink your business. But Critical Care is often overlooked, and this underutilized code can provide a significant profit margin for your practice.



As you can see, one hour of Critical Care is worth about 25% more, per case, than a Level 5 E/M charge. Of course, your experience may vary depending on your payer mix, collection rate, and current coding levels, but optimizing your CC coding has the potential to add 2-5% to your total revenue. That may not sound like much, but those are totally "free" dollars -- there is no added cost to generate that additional revenue, so it goes directly to provider compensation. Depending on your practice's overhead, that may increase physician compensation by 3-9%.

So why don't Emergency Physicians routinely code for CC time? Well, many do, and the frequency with which this code is utilized in the ED has been steadily increasing:

(Source: , representing Medicare patients only.) Some of this increase, however, may be due to the increasing practice of "boarding" critical patients in the ER waiting for inpatient beds. Some may be due to the increasing age, complexity, and acuity of patients in the ER. But it is undeniable that Emergency Physicians are catching on to the value of appropriate utilization of the CC code.

Many challenges remain to widespread adoption of this code. Many EPs are just unaware of the value of this code and the opportunity it represents. Emergency Medicine residencies do a terrible job of educating their physicians in this area, which puts young physicians at risk of losing income as they get up to speed with the business of medicine. Additionally, many EPs are a bit jaded and undervalue their services, not recognizing when they have provided critical care.

Furthermore, CC is a unique code in that it requires a break in the routine documentation flow. Unlike almost every other procedural code used in the ER, for CC, the physician must explicitly and affirmatively ask for it. For every other code, the professional coder can infer from the record what was done and apply the appropriate codes, but CC requires that the EP remember to claim it, and document in a very specific manner what was done in order to compliantly receive credit for the service provided. Critical care requires that the doctor record the time spent, the "unbundled" associated procedures, and a defensible summary of the critical illness and interventions. While not difficult, these requirements are different from those for the other 90% of patients seen in the ED, and require the EP to approach the record in a different manner that they otherwise do.

So what is "Critical Care" anyway?
The nice thing is that Medicare provided a very loose and vague definition, and left it to physicians to decide on a case by case basis. According to the most recent (PDF) : Critical care is defined as the direct delivery by a physician(s) 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 functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

There are a three key requirements which must be met for critical care:

• Time.
• Medical Necessity/Criticality.
• Interventions.

Let's address these individually.

Time:
This is a time-based code; the physician must document the total time spent in the care of this patient. The first 30-60 minutes will be billed as code 99291, and subsequent half hours will each be billed as a 99292. The time element is the most commonly missed. Frequently physicians will provide wonderful documentation of their critical care services, but failure to explicitly record the time spent will result in the case reverting to an E/M code. Coders are not allow to infer from the record how much critical care time the patient received.

The time requirement is cumulative, meaning it need not be continuous. So if the patient is in the Department for six hours, but you spent 90 minutes over this time frame devoted to the patient's care, you may bill for 90 minutes of critical care. This does includes time not at the bedside, and explicitly includes activities such as lab review, consultations, family decision-making, and documentation. You do not need to explicitly break down a line-item summary of the activities you engaged in.

A key requirement is that you must be "immediately available" to the patient during this time. For this reason, time spent off the unit cannot be included in CC time. This effectively means that providing prehospital control to EMS can not count towards the total time.

Criticality:
This is the huge subjective element in CC today, and may represent the greatest opportunity (as well as the greatest risk) for your practice. CPT provides examples of critical care which are intended to represent the "mid-range" of CC services. However, CPT also provides examples of Level 5 E/M cases which appear to meet the definition of critical care as it is currently understood. For example, any patient who experiences acute respiratory or circulatory failure requiring ventilatory support or vasopressors is clearly critical. However, a patient with unstable angina requiring intravenous nitrates, beta blockers, and anticoagulants certainly also meets the definition. Or a patient with a GI bleed requiring fluids resuscitation and transfusion. For that matter, the current definition of sepsis/SIRS is quite broad, and patients with SIRS, even early SIRS, meet the broad definition of "high probability of deterioration."

The key here is to recognize that criticality extends far beyond the intubated patient to a wide variety of conditions.

Intervention:
In order to fully justify the service you are claiming, it is necessary to have done something for the patient. That may include anything from heroic life-sustaining measures to very simple measures such as crystalloid fluid resuscitation, so long as the criticality requirements are met. The CPT definition clearly includes complex decision-making as meeting this requirement. It is, however, more justifiable when there is a tangible and clearly identifiable intervention was performed which can be said to have averted or treated the patient's actual or potential deterioration.

Documentation:
What's not required for critical care is almost as important as what is required. The standard E/M components of HPI, ROS, Past/Family/Social History, etc are not required. While you omit them at your peril (from a medical liability point of view), these are not required elements of a critical care chart from a coding and billing perspective.

It is important to understand that a variety of procedures are included, or "bundled" into CC. These are: blood draws, peripheral IV placement, blood gas interpretation, NG placement, Pulse oximeter interpretation, ventilator management, transcutaneous pacing, and CXR interpretation. You may not bill separately for these items on a critical care patient. However, all other procedures still may be billed separately, including but not limited to: intubation, central line placement, EKG interpretation, cardioversion, tube thoracostomy, laceration repair, fracture care, lumbar puncture, etc etc etc. Be aware that CPR supervision is a separately billed service, and CPR time bust therefore be subtracted from your total Critical Care time.   It is very important to explicitly note that the time you spent providing critical care services was "exclusive of all other separately billed services." Memorize that phrase and be certain to use it in every critical care dictation you do!

Compliance and Risk:
As Medicare's RAC process turns its attention to professional billing, it is predictable that this will draw its attention and that audits will result, especially in light of the increase in the utilization in these codes. As the standards are somewhat loose, how to demonstrate compliance is on everybody's mind. The key is, I think, to set standards in advance and consistently apply them, and to document explicitly the nature of the patient's criticality. In almost every critical care case, I include the statement that I felt the patient was at high risk of "X" to make it very clear to the coder (and any auditor) why I felt the patient was critical. Auditors generally give a fair amount of latitude to the judgment of the provider, so long as you explain your thoughts.

Supporting evidence of criticality which is helpful to highlight in your documentation might include:

• Obvious problems like respiratory failure or circulatory failure.
• Any organ system which has acutely failed (or may fail).
• Significantly abnormal vital signs.
• Shock, even early shock.
• Acidosis.
• Need for interventions such as central venous access, thoracostomy, cardioversion/defibrillation, transfusion of blood products, or the "ACLS" suite of IV medications.
  
• Multi-system diagnoses (aka, your "Train wrecks") requiring highly complex medical decision-making.
• Trauma patients with serious injuries.
• Patients requiring ICU admission.

ICU admission may support the criticality of the patient, but is alone not sufficient, especially if the patient is admitted as an overflow patient, or as a chronic ventilator patient.  

There is some debate regarding whether Critical Care may be justified based on the presentation alone, or whether an actual critical illness need be present.   Consider, for example, a trauma patient whose injuries turn out to be non-life-threatening.   Some claim that the patient, prospectively, was an unknown and had a high potential for deterioration.   However, the guidelines state that "both the illness or injury and the treatment must meet the requirements."  This requires that the patient has an actual illness/injury, not a potential one.    

Conversely, there may be cases in which the patient is manifestly critically ill, but the EP does not actually provide direct treatment.  For example, consider the stable patient who comes in with a cerebral hemorrhage.   If all the EP does is order the CT and call the neurosurgeon, there was no critical care provided.  If the patient required urgent blood pressure control, that would be different, but absent some intervention, Critical Care is not appropriate.  

And there are some patients who are critical but do not meet the time requirements.  In my institution, ST-Elevation MI's go very quickly to the cath lab, and are often in the ED for only fifteen or twenty minutes.   While the illness is critical, and the intensity of service provided in that time is high, the time requirement is absolute, and these patients must be coded out as level 5's.  (Using the "patient acuity" caveat for the ROS, of course.)

Frequently Asked Questions:
Can you code Critical Care on a patient who is subsequently discharged home?
Yes, but be cautious.   A compliant chart would make it quite clear that the patient was indeed critical and that there was an intervention which changed the course of their illness.   An auditor would likely be skeptical of CC on a discharged patient, so I would recommend that your documentation be bullet-proof in these events.  The most common example I can think of would be an overdose requiring temporary airway management, and things of that sort.

Can Critical Care be billed as a shared service between physicians?
No.   If two physicians of the same specialty within the same group both provide 30+ minutes of critical care on the same day, the first must be billed as 99291, with subsequent increments of 99292 as appropriate.   If each physician accounts for only 15 minutes of time, it may not be combined.

Can an ER physician bill for an E/M service and Critical Care on the same calendar date?  
Not for Medicare patients.  CMS specifically prohibits this, for the ER E/M codes only.  CPT guidelines will permit this, so long as the services provided are separately identifiable and discrete.   Some commercial payers may recognize this, but it is fairly uncommon and often will be rejected by payers.   If the patient presents prior to midnight and receives 30+ minutes of critical care both prior to and after midnight,two units of 99291 may be billed.

Can an attending bill for teaching time, or time spent by resident physicians?
Teaching time may not count towards Critical Care.   However, the attending may bill for time spent supervising the resident so long as the attending is physically in the room with thepatient while the services are being provided, and documents: "(1) the time the teaching physician spent providing critical care, (2) that the patient was critically ill during the time the teaching physician saw the patient, (3) what made the patient critically ill, and (4) the nature of the treatment and management provided by the teaching physician."  The attending may reference the resident's documentation for details.

Can a PA or Nurse Practitioner bill Critical Care time?
Yes, provided all the other guidelines are met.   As with Physicians, this may not be billed as a shared service.

In summary, Critical Care is a valuable service which we provide to our patients, and it is correspondingly well-reimbursed.   Most Emergency Department practices still do not utilize it as fully as is allowed, and optimizing your critical care coding can provide a valuable profit margin to your practice's bottom line.   However, given the increasing attention to this code, future audits are all-but-certain, and it is essential to consider the compliance elements of this code and be certain that your documentation supports the value of the services you are providing to your patients.
Comment