Note from the Associate Editorial Director: Documentation requirements for critical care services

by Melissa Varnavas

In the July 23 issue of CDI Strategies, Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, offered a tip to help CDI specialists gain physician support for improved documentation in the medical record regarding critical care. In a subsequent e-mail, Gold added comments from his “guru” on physician professional billing, Paul Dickson, MD.

Here is the amended information:

Critical care does not include ongoing monitoring of a patient who has stabilized, regardless of how many organs have failed in the past, but have now stabilized, how many lines and tubes were inserted, or how many devices were instituted. When the patient is stable, it is not critical care.

Too many physicians, however, do not realize that we can bill:

• Critical care delivery by time increments for the first encounter
• Additional critical care when the patient crashes again
• A level three subsequent visit for noncritical care in addition to the critical care delivery on the same day

Any usual evaluation and management (E/M) service appropriate for services and documentation provided may be billed prior to a critical episode, but not vice versa. Consider the following case study.

A patient presents to the cardiac care unit after a coronary artery bypass graft. The patient is intubated with a left ventricular assist device still in place but is not active and receives low-dose dopamine for renal perfusion. The patient’s vital signs are stable with a little hypotension due to lack of vascular tone due to residual effects of anesthesia, however, it is easily controlled. The external pacer is in place, chest tubes are in place to underwater seal, and diluted urine is flowing through the Foley. A physician accepts the patient onto the intensive care unit (ICU) and performs an evaluation. The patient is not critically ill. However, the patient is on a respirator, and the physician manages that respirator. This may be ventilator management 94002-3 alone, and no E /M service may be billed with these codes.

In this case, the patient does not have acute respiratory failure. Writing the words “acute respiratory failure,” means a condition exists that involves the respiratory tree due to a disease process. If, indeed, the patient does have acute respiratory failure due to a disease process when he underwent the surgery, then it is appropriate to document that, if it still exists. If this is not the case, then the presence of the words “acute respiratory failure” will give the heart surgeon a black mark since the condition would be considered a complication of the surgery.

The following are a few examples of conditions that necessitate critical care:

• Acute myocardial infarction with acute pulmonary edema
• Respiratory failure or cardiac arrest with cardiopulmonary resuscitation
• Septic shock or hemorrhagic shock
• Ventricular tachycardia with cardiogenic shock

In these situations, the patient actively experiences clinical conditions requiring physicians to administer treatments right now, help others administer treatments right now, perform bedside procedures or insert monitoring devices, (a list of included procedures is provided in AMA, CPT 2009) such as:

• Interpretation of Cardiac output measurements, Chest x-rays, and EKG’s
• Pulse oximetry
• Blood gases
• Blood pressures
• Gastric intubation
• Temporary pacemaker
• Ventilation management
• Vascular access procedures, non central

For other procedures, the intensivist may bill the critical care code along with the procedure code with the use of modifier 25 (as long as the time involved is not included in the critical care time accumulation) and watch the effects of treatments. Without these interventions, the patient would die.

There are two general functions that physicians perform in an ICU. The first is the management of complex and ill patients to maintain their stability or prevent decompensation. The second is critical care. Not all patients in the unit are critically ill nor complex, e.g., overdose, arrhythmia, etc.

The difference between the two is significant from an ethical as well as a financial viewpoint. Critical care delivery refers to care for which a hospitalist or intensivist, or other practitioner can bill a critical care CPT code in the 99291-99292 range with code 99291 for the first hour (first 30 to 74 minutes) and code 99292 (for each additional 30 minutes 75-90 minutes, etc., subsequent to the initial) for each subsequent half hour. We may report code 99292 more than once per day. For ICU services, we can also report subsequent visit codes (99231-99233) and consultation codes (99251-99255), as appropriate.

The definition of critical care helps us determine when we can report these codes. In some instances, we may be able to report multiple codes per day. Critical care refers to services rendered, either immediately at the bedside/same unit or in some other location where care is delivered for patients with life-threatening issues that, if left untreated, could immediately lead to death.

After the practicality of doing what has to be done is over, proper documentation of what physicians did, what physicians thought, or what physicians concluded is essential. However, the most important documentation requirement is the actual time you spent with the patient or assigned unit, not somewhere else in the facility as no critical care codes allow time away from the patient and his unit. Diagnoses provided should be able to support the medical necessity for the critical services. The importance of this specificity of documentation is a subject many physicians do not learn in medical school or residency.

Editor's note: Varnavas is the associate editorial director of ACDIS. Contact her at mvarnavas@acdis.org.