Critical Care Billing

Critical Care is billable procedure. The rules are somewhat complex so I’ve addressed the basics below.

Here are links to ACEP’s Critical Care FAQ’s and ALiEM‘s page on the subject.

My understanding of the basics are as follows:

  1. CPT defines critical care as “an injury or illness that acutely impairs one or more organ systems such that there is a high probability of life-threatening deterioration in the patient’s condition.”
  2. “Critical Care services” is defined as “a physician’s direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.”
  3. Examples of “vital organ system failure” include, but are not limited to:
    1. CNS
    2. Circulatory
    3. Shock
    4. Renal
    5. Hepatic
    6. Metabolic, and/or
    7. Respiratory failure
  4. Critical Care time is that of the attending – not the resident; although time you and the resident spent together on these tasks does count.
  5. The Critical Care attestation must come from the attending, the resident cannot document this for you.
  6. Unlike most procedures, critical care billing involves documenting the amount of time spent providing the critical care.
    1. There is a 30 minute minimum – exclusive of separately billable procedures (see below).
    2. It cannot be billed more than once in a calendar day, except in very uncommon situations
  7. The “critical care time” excludes the time spent doing separately billable procedures. Examples (but not an exhaustive list) include the following:
    1. CPR
    2. Intubation
    3. Chest Tubes
    4. Central Venous Access
    5. Procedural Sedation
  8. Some ‘procedures’ are not billed separately and therefore are acceptable to include into your calculation of critical care time. These include:
    1. Interpreting oxygen levels (pulse ox, for example)
    2. Interpreting blood gasses
    3. Ventilator management
    4. Gastric intubation (i.e., if you place the NGT/OGT yourself, the time spent can be counted towards critical care time)
    5. Chest X-ray interpretation
    6. Transcutaneous (but not transvenous) pacing
    7. Time spent speaking with consultants, admitting physicians, reviewing old records, or time spent speaking with family or decision making surrogates to obtain history or guide treatment

Some confusing, yet common examples:

Patient 1: Our most ‘critical’ patient’s are those receiving CPR. However, if a patient gets CPR for their entire ED course, even if it is greater than 30 minutes, but does not survive; then there was never time outside of the billable procedure: CPR. Therefore, critical care time cannot be billed.

Patient 2: On the other hand, if a patient has CPR for some period of time then achieves ROSC, critical care may be applicable in the post arrest period. If more than 30 minutes of oxygen interpretation, ABG interpretation, ventilator management, pressor/medication titration, consultant/admitting discussions, etc., occur, the critical care time requirements could be met in addition to the CPR, intubation, etc., procedures.

Patient 3: A patient with respiratory failure requiring positive pressure ventilation, but not necessarily intubation would likely meet assuming > 30 minutes were spent examining the patient, ordering/interpreting test results, managing the CPAP, discussing with admitting team, etc. Note, they don’t have to go to the CCU to meet the requirement.

Patient 4: A patient with DKA requiring an insulin drip and frequent rechecks will likely meet critical care criteria based on ‘metabolic failure.’ HHS requiring drips and frequent rechecks could meet as well for the same reason.

Patient 5: A patient with a STEMI, who clearly has the chance to decompensate, but is only in the ED for 28 minutes cannot meet critical care criteria no matter how ill they are or potentially are.

This is work you are already doing. Take the extra moment to check the boxes on the chart documenting it.