educational series | critical care

Mike Lipscomb, MDChief Quality Officer, ApolloMD

Difference in Documentation between Level 5 and Critical Care

99291 and 99292

• Does not specify any minimum number of elements listed under 99285. (Requirements on next slide.)

• 99291: First 30-74 minutes of critical care time.

• 99292: Additional 30 minute blocks of critical care time

99285

• HPI >= 4 elements

• ROS >=10 elements

• PFSH >= 2 (of 3) elements

• PE >=8 organ systems

• MDM High complexity

Mike Lipscomb, MD | Chief Quality Officer, ApolloMD

Critical CareRequirements for 99291

• Patient’s condition must meet definition of Critical Care. Provider should note patient condition as “unstable” or “critical”.

• Time spent with patient must be at least 30 minutes independent of separately reported billable procedures. Time does not need to be continuous, but additive.

• Documentation must support both of the 2 requirements above.


Critical Care Definition

CPT definition:“When a condition 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.”

CMS further defines in Medicare patient:Failure to initiate interventions on an urgent basis “would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.”


Critical Care

While counterintuitive, limb threatening injuries do not qualify as critical care unless a “vital organ system” is involved. However, management of acute blood loss

(cardiovascular system) from a limb injury would count as critical care.


Critical Care DefinitionEven if you do not spend 30 minutes of critical care time with the patient, it is good practice to note the amount of critical care time!!

2 Reasons:• This gives validity to the other critical care times noted to be more than 30 minutes. • May be billed as level 5 (99285) and eliminates the need for complete HPI/ROS/PE

requirements.

Example: “12 minutes of critical care time spent with patient.” Assuming the definition of critical care above is justified in the chart, then the code would be Level 5 (99285).


Calculation of TimeTotal accrued time devoted solely to the patient, including:

• Time at bedside (initial assessment and all reassessments)• Placing orders• Reviewing and interpreting test results• Discussing patient with staff and consultants• Family discussion to specifically obtain information on the patient’s history of event and past

medical history and any DNR discussion• Documentation of the medical record

But NOT including:• Time consoling the family or giving updates on the patient’s condition• Time performing separately billable procedures (such as intubation, line placement, chest tube

placement, CPR, supervision of CPR)


APCs and ResidentsPhysician Critical Care does not include:

• Time spent by APC or resident with the patient. (Note: APC and physician time cannot be added.) • Time spent teaching the APC or resident.

Critical Care does include:• Attending time spent directly with the patient or care as defined in previous slides.• Attending time directing the APC’s or resident’s care of the patient. (Ex. Attending while not at

bedside directs the resident to call ICU physician, intubate patient, discuss details of patient’s history with family)

If the APC spends >30 minutes of CC time but the attending does not, the critical care time must be billed under the APC billing number.


ExamplesPatients likely meeting definition (assuming > 30 minutes):

• Stroke requiring tPA or evaluation for possible neurovascular intervention• Cerebral hemorrhage requiring intubation or IV medication for BP control• Myocardial infarction in ED > 30 minutes requiring multiple medications, and possible

BP stabilization• Shock of any cause requiring vasopressors or significant fluid/blood resuscitation• Respiratory failure requiring BiPAP• Most medical conditions requiring intubation• Multiple trauma patients (with life threatening injuries). Limb threatening injuries don’t

count towards CC unless a vital organ system is threatened (severe blood loss). It needs to be a life threatening injury.

• Hypertensive emergency requiring IV medications


ExamplesPatients likely NOT meeting definition:

• 40 year old with SVT converted with adenosine after 10 minutes in ED (not critical for 30 minutes)

• 50 year old MI patient with multiple medications, phone calls, but only in ED 28 minutes (not 30 minutes)

• Psychotic patient requiring Haldol and restraints (not life threatening)• “Typical” asthma patient given IV Solumedrol and nebulizer treatments• Dispositions that are admitted to the floor or telemetry or sent home. While these

can sometimes be CC, the documentation should support a very unstable patient for more than 30 minutes that reacts well to aggressive treatments (for example, a severe allergic reaction)

• Patients with documentation of “no acute distress” or “NAD”, resting comfortably”, normal VS, benign ED course


Best Practices

Remember, the chart must include appropriatedocumentation to meet critical care definition and time.

A few examples:


Best PracticesExample #1: 99291 (Critical Care Met)

“Patient with unstable blood pressure relative to severe blood loss from melena indicating GI bleed. Ongoing IV Fluids required to maintain blood pressure initially. Discussed history with patient’s family, including Plavix and recent Motrin use. Patient with hgb drop from 12.5 last week to 7.1 today. As ongoing bleeding and significant blood loss, blood transfusion ordered along with IV Protonix. Discussed plan with on call gastroenterologist and ICU team. After family discussion, they elected for the patient to be DNR status. Total critical care time spent with patient 36 minutes.”

• Requirement #1: System identified as “unstable” (“Unstable blood pressure”)

• Requirement #2: Specific critical care time noted (“36 minutes”)

• Requirement #3: Decision making and interventions support critical care


Best PracticesExample #2: 99291 (Critical Care Met)

“Patient with acute left gaze preference and right sided weakness consistent with stroke. Neurologic status unstable. Onset 1.5 hours PTA, witnessed. Stat call to neurologist. Patient sent for emergent head CT with CTA if negative for hemorrhage. tPA discussion with family while patient at CT, indicating no contraindications for tPA. After return, radiologist called with head CT showing no acute process. Patient with limited understanding, but wife agreed with tPA and tPA treatment initiated. Discussed care with ICU team and patient admitted to ICU. No change in patient condition at time of transfer to ICU. Total critical care time 44 minutes.”

• Requirement #1: System identified as “unstable” (“Neurologic status unstable”)

• Requirement #2: Specific critical care time noted (“44 minutes”)



Best PracticesExample #3: 99285 (E/M Level 5)

“HPI: 30 year old patient with history of SVT, here with chest pain and lightheadedness. Patient is in SVT per EKG. Further HPI, ROS deferred due to unstable cardiac condition. PE: Patient is in moderate distress with complaint of chest pain. VS: T 98.5, HR 180, BP 100/55, RR 22. Lungs: Tachypnea but clear. CV: Tachycardia but regular. Further PE deferred due to unstable condition. MDM: IV placed, and Adenosine 6mg IVP ordered. The patient converted to SVT without complication. Physician at bedside for 11 minutes evaluating and caring for patient. 11 minutes critical care time.”

• This chart would code as Level 5 E/M Code 99285

• Requirement #1: System identified as “unstable” (“Unstable cardiac condition”)

• Requirement #2: Not met for 99291. Specific critical care time is “11 minutes”



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