Both clinical condition and treatment criteria must be met to qualify for critical care coding.

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1 Yale Compliance Department CRITICAL CARE FACT SHEET Critical care, evaluation and management; first minutes Critical care, evaluation and management, each additional 30 minutes Note: Please see the current CPT manual regarding separate guidelines for neonatal & pediatric critical & intensive care services (CPT codes , , , & ). DEFINITION: Critical Care is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury is one that 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, and the patient s survival is jeopardized (e.g. central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, respiratory failure, post operative complications, or overwhelming infection). (CPT) CLINICAL CONDITION CRITERION: There is a high probability of sudden, clinically significant, or imminent or life threatening deterioration in the patient s condition that requires the highest level of physician preparedness to intervene urgently. The presence of the patient in an ICU or CCU or the patient s use of a ventilator is not sufficient to warrant the use of critical care codes. The documentation must substantiate the physician is performing a critical care service. (CPT) TREATMENT CRITERION: Critical care services require a physician s direct personal supervision and management of life and organ supporting interventions that may require frequent manipulation by the physician. These services involve 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. Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient s condition. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient s condition continues to require the level of physician attention described above. (CPT, Centers for Medicare and Medicaid Services (CMS) Transmittal 1548 & Medicare Provider News, No.55. Quarterly Edition, April 2000) Both clinical condition and treatment criteria must be met to qualify for critical care coding. GENERAL For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patients during the same period of time. (CMS IOM Chapter 12 sect c) When the patient is unable or clinically incompetent to participate in discussions, time spent on the unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient s condition or prognosis, or discussing treatment or limitations of treatment may be reported as critical care, provided that the discussion bears directly on medical decision-making. (CMS IOM Chapter 12 sect c) Other discussions with family members, no matter how lengthy, that do not meet the appropriate criteria, including regular or periodic updates of the patient s condition and/or emotional support, cannot be counted as critical care. (Only discussions related to decision-making regarding treatment, as described above, may be counted towards critical care time.) (HCFA Program Memo 12/1999 & Medicare Provider News, No.55. Quarterly Edition, April 2000) 1

2 The physician s thought process and analysis to reach the conclusion must be documented. A note simply stating that a patient s condition is stable without documenting what analysis is being provided to arrive at that conclusion and what vital organ failure is being prevented would not be sufficient. (YNH Attorney, Hogan Hartson-1999) A surgeon can be reimbursed for critical care services in the post-op period if the above criteria are met. See FAQ for more information. (HCFA Program Memo 12/1999) Any number of physicians may provide and bill critical care for the same patient on the same date, if the services are medically necessary and the patient s condition and the care rendered meet the definition of critical care. (FSCO Medicare B update Nov 2006) If two physicians of the same specialty, in the same group, provide critical care to the same patient on the same date, they must bill as if they were one physician, combining their time and reporting and (if applicable) the appropriate number of units of (Centers for Medicare and Medicaid Services (CMS) Transmittal 1548) Example: Two pulmonary specialists, who share a group practice, each provide critical care services (at different times during the same day) to a patient who has multiple organ dysfunction (including cerebral hematoma, flail chest and pulmonary contusion), is comatose, and has been in the intensive care unit for 4 days following a motor vehicle accident. Both physicians may report medically necessary critical care services provided at the different time periods. One physician would report CPT code for the initial visit and the second, as part of the same group practice, would report CPT code on the same calendar date if the appropriate time requirements are met. (Centers for Medicare and Medicaid Services (CMS) MLN Matters MM5993) If physicians are of different groups and/or specialties, they may each provide and bill critical care services to the same patient on a given date, if the services are medically necessary, and the two physicians are providing care that is unique to his/her medical specialty and managing at least one of the patient s critical illness (es) or critical injury (ies). In this instance the initial critical care service may be payable to each. (Centers for Medicare and Medicaid Services (CMS) Transmittal 1548) If a physician or qualified NPP within a group provides staff coverage or follow-up for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the covering physician or qualified NPP in the group shall be billed using CPT critical care add-on code The appropriate individual NPI number shall be reported on the claim. The services will be paid at the specific physician fee schedule rate for the individual clinician (physician or qualified NPP) billing the service. (Centers for Medicare and Medicaid Services (CMS) Transmittal 1548) The use of critical care codes is not based on location. (HCFA Program Memo 12/1999) Examples that do not satisfy Medicare s criteria for critical care payment include: -Patients admitted to a critical care unit because no other hospital beds were available -Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs - Patients admitted to a critical care unit because hospital rules require certain treatments (e.g. insulin drips) to be administered in the critical care unit (Medicare Provider News, No.55. Quarterly Edition, April 2000) 2

3 The following services are included in reporting critical care when performed during the critical period by the physician(s) providing critical care: (CPT) Interpretation of cardiac output measurements (93561, 93562) Chest x-rays (71010, 71015, 71020) Pulse oximetry (94760, 94761, 94762) Blood gases, and information data stored in computers [e.g. ECGs, blood pressures, hematologic data (99090)] Gastric intubation (43752, 43753) Temporary transcutaneous pacing (92953) Ventilatory management ( , 94660, 94662) Vascular access procedures (36000, 36410, 36415, 36591, 36600) Any services performed which are not listed above should be reported separately. The time spent in the performance of separately billable procedures should not be counted in the critical care time component. (CPT) TIME Documentation of total time spent by a physician with the individual patient should be recorded in the patient s medical record even if the time spent is not continuous. (CPT) Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E&M code. (CPT) The physician s progress note must document that time involved in the performance of separately billable procedures was not counted toward critical care time. (Medicare Provider News, April 2000 ) TEACHING PHYSICIAN The Teaching Physician must be present for the period of time, which the claim was made. Time spent by the resident in the absence of the teaching physician cannot be billed by the physician as critical care. Only time spent by the resident and teaching physician together with the patient, or the teaching physician alone with the patient, can be counted toward critical care time. (Medicare Provider News, No.55. Quarterly Edition, April 2000) A combination of the teaching physician s documentation and the resident s documentation may support critical care services. Provided that all requirements for critical care services are met, the teaching physician documentation may tie into the resident's documentation. The teaching physician may refer to the resident s documentation for specific patient history, physical findings and medical assessment. However, the teaching physician medical record documentation must provide substantive information including: Time the teaching physician spent providing critical care; That the patient was critically ill during the time the teaching physician saw the patient; What made the patient critically ill; and The nature of the treatment and management provided by the teaching physician. The medical review criteria are the same for the teaching physician as for all physicians. (Centers for Medicare and Medicaid Services (CMS) Transmittal 1548) It is not acceptable if the resident documents that he/she is rounding with the teaching physician and for the teaching physician to document, "seen, examined & agree with the resident. The medical record must support the presence, activity & involvement of the teaching physician. (Pennsylvania Medicare Report 3/2001) Acceptable Example of Documentation: "Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this 3

4 condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident's documentation and I agree with the resident's assessment and plan of care." (Centers for Medicare and Medicaid Services (CMS) Transmittal 1548) CRITICALITY The patient must be critically ill or critically injured. The physician defines criticality for both professional and facility reimbursement. However, the documentation must support that the patient is critically ill or injured in order to assign critical care. 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. 1. Although critical care may be delivered in a moment of crisis or upon being called to the patient s bedside emergently, this is not a requirement for providing critical care service. Critical care may be assigned without a full cardiac or respiratory arrest occurring. (Centers for Medicare and Medicaid Services (CMS) Transmittal 1548) 2. Daily management of a patient on chronic ventilator therapy does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the ventilator dependence. (Centers for Medicare and Medicaid Services (CMS) Transmittal 1548) 3. Centers for Medicare and Medicaid Services (CMS), formerly HCFA, states that providing medical care to a critically ill patient should not be automatically determined to be a critical care service for the sole reason that the patient is critically ill. CMS and CPT further state the providing of medical care to a critically ill, injured or postoperative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the requirements. CPT provides clinical examples for all Evaluation and Management codes. Included below are several clinical examples of what CPT considers patients who would warrant a (Critical Care Service) versus those listed as meeting the clinical example of a (Subsequent Hospital Care Visit). CPT CLINICAL EXAMPLES Critical Care Service (99291): First 30 minutes of critical care of a 15-year-old with acute respiratory failure from asthma. First hour of critical care of a 65-year-old with septic shock following relief of a urethral obstructions caused by a stone. 4

5 First hour of critical care of a 45-year-old who sustained liver laceration, cerebral hematoma, flailed chest, and pulmonary contusion after being struck by an automobile. First hour of critical care of a 65-year- old woman who, following a hysterectomy, suffered cardiac arrest associated with pulmonary embolus. Subsequent Hospital Care (99233): Subsequent hospital care visit for a 50-year old male, post aortocoronary bypass surgery now develops hypotension and oliguira. Follow-up visit for a chronic renal failure patient on dialysis who develops chest pain and SOB and a new onset of pericardial friction rub. Subsequent hospital visit for 62-year-old female, known liver cirrhosis patient, with recent upper GI bleed and varices; now with worsening ascites and encephalopathy. CMS EXAMPLES (Source: CMS Transmittal 1548) Critical Care Service ( 99291): An 81 year old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent. A 67 year old female patient is 3 days status post mitral valve repair. She develops petechiae, hypotension and hypoxia requiring respiratory and circulatory support. A 70 year old admitted for right lower lobe pneumococcal pneumonia with a history of COPD becomes hypoxic and hypotensive 2 days after admission. A 68 year old admitted for an acute anterior wall myocardial infarction continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy. VIGNETTES (Source: George Sample, MD) Critical Care Services & Subsequent Hospital Care Visits The physician is called to the floor to evaluate a 62-year-old male admitted via the ER 1 hour ago for severe COPD. When seen the patient is in severe respiratory distress, ABGs reveal profound respiratory acidosis. You initially apply BiPAP (NPPV), but the patient becomes more obtunded. He is intubated, moved to ICU and placed on A/C mode mechanical ventilation. BP is now 80/40 and u/o is poor-both respond to 500 cc s saline infusion (time spent 1 hour). You then spend an additional 30 minutes in the ICU with the patient s family explaining the overall poor prognosis and treatment options due to the patient s unresponsiveness. CODEs 99291, Critical care (first minutes) & 99292, Critical care (each additional 30 minutes) The physician is called to the floor to evaluate a 55-year-old male with severe COPD & bronchospasm; initially admitted to ICU for acute respiratory distress requiring mechanical ventilation. The patient is stabilized, extubated and transferred to the floor, but has now developed an acute fever, dyspnea, left lower rhonchi & carbon dioxide retention & hypoxemia. Interventions include Stat inhalation therapy, IV antibiotics and a repeat carbon dioxide level in two hours. CODE 99233, Subsequent Hospital Care visit A 50-year-old male, post aortocoronary bypass surgery now develops hypotension and oliguria. (This is a clinical example, found in Appendix D of CPT 2001) CODE 99233, Subsequent Hospital Care visit A 50-year-old male, post aortocoronary bypass surgery now develops hypotension and oliguria. His LOC has decreased; pulse is thready at 130; diaphoretic; mottled knees; decreased capillary refill; no gallop noted. He received 1000cc Hespan w/o success. Because of his active hemodynamic instability & life threatening risk of worsening cardiogenic shock, a 5

6 PAC will be placed. 40 minutes was spent at the bedside monitoring; his response to volume infusion; rhythm strip; reviewing CXR/EKG/lytes. This time did not include PAC placement. CODE , Critical care & 93503, PAC A 62-year-old female admitted with acute subarachnoid hemorrhage, negative cerebral arteriogram, increased lethargy and hemiparesis with fever. (This is a clinical example, found in Appendix D of CPT 2001) CODE 99233, Subsequent Hospital Care visit A 62-year-old female admitted with acute subarachnoid hemorrhage, negative cerebral arteriogram, increased lethargy and hemiparesis with fever. Due to the imminent neurological instability & potentially life threatening risk she faced from vasospasm, a CVP was placed. She was started on hypertensive therapy with norepinephrine to reach a MAP of 110; hypervolemic therapy to attain a CVP of Minutes spent at the bedside, administering critical care services, including neurological checks, assessing ABG's/lytes/CVP's. This time did not include CVP placement. CODE , Critical care & 36489, CVP 6