Documentation Guidance for Reporting Critical Care Services

Hello and Welcome to our podcast series. My name is Meghann Drella and I am a Senior Solutions Manager here at Outsource Strategies International. Today, I will be discussing how to report critical care services.

When reporting critical care services, physicians should document medical necessity and ensure that the patient meets the definition of critical care. Critical care medicine specialists diagnose and treat a wide variety of diseases. A multidisciplinary of team approaches needed to care for critically ill patients. Though there are only two codes for critical care services, reporting critical care presents a challenge because of the rules and regulations involved. In fact, Medicare and commercial payers scrutinize the manner in which critical care services are billed. Documentation of medical necessity is crucial.

Critical care services are the professional services provided to patients with a critical illness or injury. To report the services accurately, it is necessary to understand what constitutes critical care.

Both CPT and Medicare have provided definitions of critical care. According to CPT 2017,“Critical care is the direct delivery by a physician or other qualified health professional of 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 to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.”

Medicare and other payers add that critical care should be medically necessary as the 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.

Medical necessity is defined by Medicare as “health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meets standard acceptance of medicine.” The documentation must clearly convey the reasons why the diagnostic and treatment decisions were made.

Common conditions that require critical care are:

• Heart problems
• Lung problems
• Organ failure
• Brain trauma
• Blood infections or sepsis
• Drug-resistant infections or serious injury

How can a practitioner determine what constitutes critical care? The Society of Critical Care Medicine cautions that when reporting services, physicians should ensure that the patient meets the definition of critical care. There are many instances where the patient may be in the critical care unit, but does not meet the critical care criteria.  For instance, a patient receiving chronic ventilation in the critical care unit may not be considered critical unless they meet the critical care definition.

There are two CPT codes for adult critical care services: 99291 and 99292

• 99291 is critical care, evaluation and management for the first 30–74 minutes
• 99292 is each additional 30 minutes

To report these codes, the physician’s documentation must support the critical care claim with details such as their condition, the services provided, the time spent rendering care, and any other relevant information.

According to AMA CPT 2017 and CMS Publication 10-4, here some important guidance about documenting time as provided by the SCCM:

• There is no specific rule that start times and stop times for critical care must be documented for Medicare patients.
• The documentation should reflect that the time spent performing procedures or services not included in critical care, was not counted.
• Besides bedside procedures that were performed on the same day as critical care can be reported separately. To get paid for the procedure, the critical care service should be reported with modifier 25
• If a procedure performed is included in critical care services, the time for performing the procedure must be included in the physician’s critical care time. The procedure must not be reported separately because it’s bundled into critical care.
• To report critical care time, the physician or nonphysician provider must be immediately available to the patient.
• Only one practitioner can bill for critical care during a specific time period though more than one physician is managing the patient.
• Critical care can be intermittent and provided at various times during a particular day. To bill services for the particular date of service, all time for that date should be totaled and reported based on total time.

Physicians must also know when time involved with family members or other surrogate decision makers may be counted towards a critical care.

When it comes to critical care services, the red flags that will attract the attention of insurance carrier to avoid an audit or inaccurate coding, insufficient lack of documentation, non-adherence to payer policies, lack of medical necessity. Unbundling procedures included in critical care or overuse of modifiers can also trigger an audit. The following best practices can reduce risk of payer audits:

• Ensure accurate and up-to-date CPT and ICD-10 codes
• Provide comprehensive documentation
• Make sure documentation supports the medical necessity
• Be familiar with Medicare and private payer rules
• Avoid overutilization of critical care services
• Unbundling services inappropriately
• Perform regular self-audits on areas of risk

I hope this helps, but always remember that documentation as well as a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.

Thank you for joining me and stay tuned for my next podcast.