Case Based for March

Chief Complaint

“Confusion and weakness”

History of Present Illness

A 72-year-old male with a history of diabetes and hypertension is brought in by EMS for altered mental status. Patient unable to give a history due to current mental status. Family reports 2 days of fever, decreased oral intake, and progressive confusion. Today he became difficult to arouse.

Brief Physical Exam

Initial Vitals Temp: 39.2°C, HR: 128 bpm, BP: 78/46 mmHg, RR: 26, SpO₂: 91% on room air

General: Ill-appearing, obtunded

HEENT: Dry mucous membranes

Heart: Tachycardic, weak pulses, no murmurs, rubs or Gallops, Delayed capillary refill

Lungs: coarse breath sounds, no wheezes, increased rate

Skin: mottled, cool to touch, no rashes

Brief ED Course / Medical Decision Making

Patient identified as being in septic shock with acute organ dysfunction (altered mental status, hypotension).

Immediate interventions:

• Rapid IV fluid resuscitation (30 mL/kg crystalloid)
• Broad-spectrum IV antibiotics within 1 hour
• Initiation of vasopressors (e.g., norepinephrine) for persistent hypotension
• Continuous cardiac and hemodynamic monitoring
• Frequent reassessments of perfusion and mental status

Diagnostics:

• Blood cultures ×2 prior to antibiotics
• Lactate elevated at 5.2 mmol/L
• CBC: leukocytosis
• CMP: acute kidney injury
• Chest X-ray: right lower lobe pneumonia

Why This Qualifies for Critical Care Time

This patient meets criteria because:

• High probability of imminent life-threatening deterioration (shock, organ failure)
• Active physician management required to prevent death
• Multiple organ systems involved (cardiovascular, neurologic, renal)
• Time-intensive interventions and reassessments

Example Critical Care Documentation Statement

“The patient was critically ill with septic shock and acute organ dysfunction. I was immediately available and provided direct management including aggressive fluid resuscitation, initiation of vasopressors, interpretation of diagnostic studies, and continuous reassessment. The patient was at high risk for cardiovascular collapse and death. A total of 45 minutes of critical care time was provided, exclusive of separately billable procedures.”

Critical care is the direct delivery of medical care by a physician or qualified healthcare professional to a critically ill or injured patient, involving high-complexity decision-making to treat or prevent life-threatening organ system failure.

CMS Definition of Critical Care

Critical care billing can be justified if the patient has a medical condition that “impairs one or more vital organ systems” and “there is a high probability of imminent or life-threatening
deterioration in the patient’s condition.” The physician should also provide “frequent personal assessment and manipulation” of the patient’s condition. Many conditions that qualify for critical
care billing are obvious, such as cardiac arrest, life-threatening traumatic injuries, and most conditions that result in intensive care unit admission. However, emergency physicians take care of many other
conditions and provide many interventions that may also justify critical care billing {see Table 1 from ACEP’s guidelines (Critical Care FAQ]).

Table 1: Conditions and interventions that often qualify/a re associated with critical care billing

 

CONDITIONS that frequently qualify for critical care billing                                                             INTERVENTIONS often associated with critical care billing

Acute coronary syndrome with active chest pain
Acute hepatic failure                                                                                                                                  Arterial line placement
Acute renal failure                                                                                                                                     Burn care, major
Acute respiratory failure                                                                                                                            Cardiopulmonary resuscitation
Adrenal crisis                                                                                                                                             Chest tube insertion
Aortic dissection                                                                                                                                        Cricothyrotomy
Bleeding diatheses – aplastic anemia, DIC,                                                                                                Defibrillation/ Cardioversion
hemophilia, ITP, leukemia, TTP                                                                                                                  Delivery of baby
Burns threatening to life or limb                                                                                                               Emergent blood transfusions
Cardiac dysrhythmia requiring emergent treatment                                                                                 Endotracheal intubation
Cardiac tamponade                                                                                                                                   Hemorrhage control, major                                                                                                                                 Coma (most etiologies, except simple hypoglycemic)                                                                              Intravenous pacemaker insertion
Diabetic ketoacidosis or non-ketotic hyperosmolar                                                                                 Invasive rewarming
syndrome                                                                                                                                                  Non-invasive positive pressure ventilation (i.e. BiPAP or CPAP)
Drug overdose                                                                                                                                          Pericardiocentesis
Ectopic pregnancy with hemorrhage                                                                                                       Therapeutic hypothermia
Embolus of fat or amniotic fluid                                                                                                               Trauma care requiring multiple surgical interventions or consultants
Envenomation                                                                                                                                           Ventilator management
Gastrointestinal bleeding                                                                                                                          Parenteral medications necessitating continuous monitoring, such as

Head injury with loss of consciousness                                                                                                    • ACLS medications administered during cardiac arrest

Hyperkalemia                                                                                                                                           • Insulin infusions                                                                                                                                                   Hyper- or hypothermia                                                                                                                            • Medications for heart rate/rhythm control
Hypertensive emergency                                                                                                                         • Naloxone infusions
lschemia of limb, bowel, or retina                                                                                                            • Vasoactive medications

Lactic acidosis
Multiple trauma
Paralysis (new onset)
Perforated abdominal viscous
Ruptured aneurysm
Shock, all etiologies (septic, cardiogenic, spinal,
hypovolemic, anaphylactic)
Stroke, hemorrhagic (all etiologies) or ischemia

Status epilepticus
Tension pneumothorax
Thyroid storm

Time Spent on Critical Patient Care

The amount of time spent providing critical care time must be clearly recorded and is billed by unique codes. This is a distinct difference from E/M code billing that is performed on most other
patients. To bill critical care time, emergency physicians must spend 30 minutes or longer on patient care.

Table 2: Three Current Procedural Terminology (CPT) codes used for critical patient care

CODE                                                                                                                       SERVICE
99291                                                                                                                       Used to report the additive total of the first 30-74 minutes of critical care performed on a given date. Critical care time totaling                                                                                                                                     less than 30 minutes is reported using the appropriate E/M code.

99292                                                                                                                       Added to 99291 to report each additional 30 minutes beyond the first 74 minutes

G0390                                                                                                                       Added to 99291 for Trauma Team Activation when appropriate activation criteria are met at designated trauma centers

 

Both direct and indirect patient care time can be included in critical care billing. Therefore, time spent evaluating the patient, speaking with EMS pre hospital personnel and family, interpreting studies,
discussing the case with consultants or admitting teams, retrieving data and reviewing charts, documenting the visit, and performing bundled procedures should all be included in the critical care
time recorded. One important exception is that the time spent on any separately-billed procedures should not be included in the critical care time.

Table 3: Procedures which are commonly bundled versus billed separately from critical care time

Common Procedures BUNDLED into Critical Care Time Billing                                                            Common Procedures Billed SEPARATELY

Interpretation of cardiac output, chest x-rays, pulse oximetry, blood                                                         Endotracheal intubation
gases, information/data stored in computers                                                                                              Central vascular access
Gastric intubation (e.g. nasogastric tubes)                                                                                                   lntraosseous line placement
Temporary trainscutaneous pacing                                                                                                              Transvenous pacing
Ventilatory management                                                                                                                              Chest tubes
Blood draws for specimen                                                                                                                            CPR
Peripheral vascular access                                                                                                                            Wound repair
ECG interpretation
Electrical cardioversion

While you do not need to carry a stopwatch to time yourself on every direct and indirect patient care task, you should accurately track and document the total time you spend providing critical care
services to a given patient. It is important to remember a few things about critical care time:

1. It is additive.
2. It may only be billed once per day per patient .
3. It does need not be continuous.
4. Critical care time does require the direct involvement and documentation by an attending
physician. (Sorry residents! Your efforts are appreciated but if your attending leaves you alone
with a critical patient t hat time is not reimbursable.)

Documenting Critical Care Time

The chart must provide adequate justification for why a patient meets CMS criteria for critical care
billing. To do this, explain all of the following:

1. How the patient was critically ill
2. What you did for the patient
3. The cumulative critical care time spent on direct and indirect patient care

Try to document the following points, when applicable:

1. Severity of illness and potential for decompensation
2. Vital signs (hypotension, hypoxia, etc.) and how these changed through the case
3. Tests performed and your interpretation of the results
4. Treatments provided, including: supplemental oxygen, IV fluids, medications, blood transfusions,
burn/wound care
5. Procedures performed
6. Re-assessments of the patient’s status and response to interventions
7. Conversations with EMS, the patient, the patient’s family or surrogate decision makers, nursing
home personnel, consultants, and admitting teams
8. Information retrieved by chart review and how this impacted patient care

You may notice that these documentation guidelines differ from the E/M coding guidelines that are
applied for non-critical care patients. That is because a chart associated with critical care time will not
have an E/M level associated with it as these codes are mutually exclusive. However, if the
documentation of a critical care case does not meet CMS standards, or if the total critical care time is
less than 30 minutes, the chart will be billed according to E/M codes. If there is any concern that the
chart will not meet critical care criteria; providers should also document according to the appropriate
E/M coding coding guidelines.

Revisiting the Case

Let’s get back to our case of the patient presenting with a STEMI and a subsequent rapid disposition to
the cardiac catheterization lab. Although that patient met the CMS critical care organ system
dysfunction and high-risk for decompensation criteria, the provider spent less than 30 minutes of
cumulative time on direct and indirect patient care. It is fairly rare that you are able to evaluate a
patient, interpret all studies, and complete all documentation on a critical care patient within 30
minutes but it does happen. The patient’s chart was thus billed at a Level 3 visit (E/M code #99283).
Thus if there is a possibility that a patient’s chart may not qualify for at least 30 minutes of critical care
time, as was the case above, be sure to chart appropriately based on E/M coding levels.

Work Smarter, Not Harder

• Emergency physicians frequently provide critical! care (by billing standards) to patients but do not
even recognize that they are doing so.. Reflect on your practice and consider if you are missing
critical care billing opportunities.
• A chart that qualifies for critical care time does not require the detailed history and physical
exam points required for E/M level billing on non-critical care patients. Use this to your
advantage by focusing more on the medical decision-making portion of the chart. You do need to
document how the patient was critically ill, what you did for the patient, and the number of
minutes you spent caring for the patient.
• Using a macro or template can help you provide adequate critical care documentation in a timely
manner.

 

Additional Information may be found at ACEP Critical Care Medicine: Critical Care Billing and Coding Review and Updates for 2024 | Critical Care Medicine Section

 

 

Written by Paula Silha, MD

ERx Clinical Partners Physician and CMO

This is for informational purposes only. For medical advice or diagnosis, consult a physician