(*)Rebecca B. Parker, MD, FACEP
Chair, ACEP Board of Directors; Executive Vice
President, EmCare North Division; President,
Team Parker LLC; Clinical Assistant Professor,
Texas Tech-El Paso, Dept. of Emergency
Medicine
Advanced Procedure Coding for
Emergency Medicine
January 15-16, 2015
Las Vegas, NV



Critical Care Coding: What Coders and
Physicians Both Need to Know
Review multiple specific critical care clinical
presentations and dispel common misperceptions
regarding who qualifes for critical care
Discuss critical care coding issues including:
bundled services, time requirements, and CPR
Identify documentation and coding requirements to
appropriately report critical care services
1/15/2015
9:00:00 AM-10:00:00 AM
TH-04
Las Vegas Ballroom
DISCLOSURES:
(*) Ownership Interest: Team Parker
1/3/2015
Critical Care
Rebecca Parker, MD, FACEP
Chair, ACEP Board of Directors
Executive Vice President, EmCare North Division
President, Team Parker LLC
Objectives
 Identify documentation and coding requirements to
appropriately report critical care services
 Discuss critical care coding issues including: bundled
services, time requirements, and CPR
 Review and dispel common misperceptions regarding
specific critical care clinical presentations
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Critical Care Definition
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CPT & CMS Definition
An illness or injury that 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.
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CPT & CMS Definition
Critical care services are a physician’s direct delivery
of medical care for the critically ill or 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.
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CPT & CMS Definition
 Examples of vital organ systems include, but not limited
to:




CNS failure
Circulatory failure
Shock
Renal, hepatic, metabolic, and/or respiratory failure
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CMS Adds
“…the failure to initiate these interventions on an
urgent basis would likely result in sudden, clinically
significant or life threatening deterioration of the
patient’s condition.”
It must be medically necessary and reasonable.
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North Division KISS
To meet CC requirements, answer YES to all 3 questions:
1. Is at least one vital organ system acutely impaired?
2. Is there a high probability of imminent, lifethreatening deterioration?
3. Did you intervene to prevent further deterioration of
the patient’s condition?
**In addition to YES, the physician request and time requirement
greater than 30 minutes must be met
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CPT Definition:99285
 Emergency department visit for the evaluation and
management of a patient, which requires these 3
key components within the constraints imposed by
the urgency of the patient's clinical condition
and/or mental status:
A comprehensive history;
A comprehensive examination; and
Medical decision making of high complexity
 Usually, the presenting problem(s) are of high
severity and pose an immediate significant threat
to life or physiologic function.
CPT Appendix C: 99285 Examples

Emergency department visit for a patient with a complicated overdose requiring aggressive
management to prevent side effects from the ingested materials.

Emergency department visit for a patient with a new onset of rapid heart rate requiring IV
drugs.

Emergency department visit for a patient exhibiting active, upper gastrointestinal
bleeding.

Emergency department visit for a previously healthy young adult patient who is injured in
an automobile accident and is brought to the emergency department immobilized and has
symptoms compatible with intra-abdominal injuries or multiple extremity injuries.

Emergency department visit for a patient with an acute onset of chest pain compatible
with symptoms of cardiac ischemia and/or pulmonary embolus.

Emergency department visit for a patient who presents with a sudden onset of "the worst
headache of her life," and complains of a stiff neck, nausea, and inability to concentrate.

Emergency department visit for a patient with a new onset of a cerebral vascular
accident.

Emergency department visit for acute febrile illness in an adult, associated with shortness
of breath and an altered level of alertness.
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CPT Appendix C: 99291 Examples
 First hour of critical care of a 65-year-old male with septic shock
following relief of ureteral obstruction caused by a stone.
 First hour of critical care of a 15-year-old with acute respiratory
failure from asthma.
 First hour of critical care of a 45-year-old who sustained a liver
laceration, cerebral hematoma, flailed chest, and pulmonary
contusion after being struck by an automobile.
 First hour of critical care of a 65-year-old female who, following
a hysterectomy, suffered a cardiac arrest associated with a
pulmonary embolus.
 First hour of critical care of a 6-month-old with hypovolemic
shock secondary to diarrhea and dehydration.
 First hour of critical care of a 3-year-old with respiratory failure
secondary to pneumocystis carinii pneumonia
99285 vs 99291
 Considerable overlap between 99285 and 99291 CPT
descriptors
 Appendix C 99285 and 99291 examples also
 99285 examples tend to suggest a high risk presentation
 MVA compatible with intra-abdominal/extremity injuries
 99291 examples consistent with high risk presentation
PLUS positive finding or dx
 Auto ped with liver lac, pulmonary contusion
 Septic shock
 CMS: need to intervene to prevent deterioration
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Critical Care
 Total (all payer) rate
 about 3-6% of E/M codes depending on type of ED
 2013 BESS (Medicare only)





National: 7.4%
CO: 5.8 %
TX: 8.2%
CA-S: 10.0%
KS: 5.8%
 Must be audit defensible
 Documentation and policy
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Cahaba
Part B Critical Care CPT 99291 Widespread
Prepayment Targeted Review Results
Posted July 19, 2013 in Part B
Medical Review (MR) Part B has recently completed the
widespread prepayment widespread targeted review of CPT
99291, Critical Care, Evaluation and Management of the Critically
Ill or Injured Patient: First 30-74 Minutes. Claims which met the
edit parameters were randomly selected across the provider
community. The error rates for this review were 80% for Alabama,
92% for Georgia, and 70% for Tennessee. Based on the outcomes
of this review the prepayment widespread targeted review will
be continued.
Review of the claims submitted indicated that the documentation
did not support critical care services were provided as submitted
on the claim by the billing of 99291.
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Cahaba
Medical record reviews indicated the following:
Critical care time was not documented; the reviewer could not determine
the amount of time the physician and/or hospital staff spent with patients.
CPT 99291 was billed with less than 30-74 minutes documented;
Examples:
Total critical care time of 15 minutes was documented in the record
Patient had arrived on full life support and was pronounced dead soon after
arrival
Documentation did not support that the physician and/or hospital staff
were engaged in active face to face critical care of a critically ill or
critically injured patient.
CC justification:”… just, like your
opinion, man”
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Critical Care Value
 99285
 2015 WRVU: 3.80
 2015 MFS: $175.43
 99291
 2015 WRVU: 4.50
 2015 MFS: $225.19
 Missed CC = about $50 lost revenue
 60k/yr ED goes from 2 to 4% CC
 Revenue increases by over $60,000/yr
 Must still be compliant and defensible!!!
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Critical Care Time
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Critical Care Time
(MLN Matters Number: MM5993 Revised)
Critical Care Time
 Time based code
 Must meet 30 minutes
 CC time defined as
 At the bedside
 On the unit and immediately available to patient
 Full attention: cannot provide services to any other
patient during that period of time
 May be aggregated – doesn’t need to be continuous
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Critical Care Time
 CC time defined as (cont):
Reviewing test results or imaging studies
Discussing patient’s care with staff
Documenting in the record
Time spent with other decision makers when patient is
unable to make decisions
 Time to perform procedures such as gastric intubation,
temporary transcutaneous pacing, ventilator management,
peripheral vascular access




Bundled Procedures: Transmittal
1548
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CC Time Conundrums
 CMS and CPT agree:
 MLN Matters Number: MM5993 Revised: Time spent off the
unit or floor where the critically ill/injured patient is
located (i.e., telephone calls, whether taken at home, in
the office, or elsewhere in the hospital) floor may not be
reported as critical care time because the physician is not
immediately available to the patient. This time is
regarded as pre- and post service work bundled in
evaluation and management services.
CC Time Conundrums
 CMS: Concurrent critical care services provided by each
physician must be medically necessary and not provided
during the same instance of time.
 CPT: Only one physician/provider may report services
for a given hour of critical care, even if more than one
physician/provider has rendered critical care to the
patient (CPT Assistant July ’06).
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CC Time Conundrums
 Time spent speaking with family members or surrogate
decision-makers counts if (MLN Matters Number:
MM5993):
 The medically necessary treatment decisions for which the
discussion was needed;
 The patient is unable or incompetent to participate in giving
history and/or making treatment decisions;
 The necessity to have the discussion (e.g., "no other source
was available to obtain a history" or "because the patient was
deteriorating so rapidly I needed to immediately discuss
treatment options with the family"; and
 A summary in the medical record that supports this medical
necessity.
 CPT policy is consistent with CMS
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CC Time Conundrums: ACEP FAQ
 Scenario 1: How would you code a patient who presents to the
ED at 2335 Day 1, with CC services beginning at that time and
performed continuously until 0015 on Day 2, with no more CC
services performed on Day 2?
Answer: Critical care 99291 can be reported for Day 1.
 Scenario 2: How would you code a patient who presents to the
ED at 2335 Day 1, with CC services beginning at that time and
performed continuously until 0015 on Day 2, at which time
continuous CC services are interrupted; CC services are
reinitiated at 0030 Day 2, with an additional 65 minutes provided
on Day 2 following the re-initiation?
Answer: Critical care 99291 can be reported for Day 1, and a
second 99291 reported for Day 2.
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CC Time: Procedures
 Time spent performing unbundled procedures is not
considered as counting toward CC time
 Unbundled procedures are separately billed
 Examples
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Wound repair
Intubation
Chest tubes
Central lines
CPR
CC Time: CPT Assistant
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July 2012
Question: May a physician report CPT code 92950 for chest
compressions performed by another member of the clinical team
when the physician manages the cardiopulmonary resuscitation?
Answer: Yes. If the physician manages the cardiopulmonary
resuscitation (and is present face to face), then the physician may
report code 92950, Cardiopulmonary resuscitation (eg, in cardiac
arrest). It is not required that the physician performs the actual
chest compressions and/or mouth to-mouth resuscitation or bagging
in order to report code 92950. It is also appropriate for a physician
to report code 92950 with codes 99291 and 99292 (for the critical
care services) when cardiopulmonary resuscitation and critical care
services are performed on the same day by the same physician.
Both services should be clearly documented in the medical record.
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NPPs (Non-Physician
Providers)
CC Time: NPPs
 Non-physician practitioners (NPP)
 May report 99291/92 using NPP NPI if CC is within state and
hospital scope of practice
 CMS: Shared service between physician and NPP may not
be reported as sum of individual times.
 Must report based on either NPP or physician time
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CPT 2013
 Editorial change to clarify usage by NPPs
 Critical care is the direct delivery by a physician(s) or
other qualified health care professional of medical care
for a critically ill or critically injured patient
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Teaching Physicians
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Critical Care Time: Teaching
Physicians
 Time that does not count
 Teaching time at the bedside
 Resident time alone at the bedside
 CMS: “The medical review criteria are the same for the
teaching physician as for all physicians…”
 Documentation
 TP note may tie into resident note but must support all CC
criteria
Critical Care and Teaching
Physicians
CMS: The teaching physician medical record
documentation must provide substantive information
including:
(1) the time the teaching physician spent
providing critical care,
(2) that the patient was critically ill during
the time the teaching physician saw the patient,
(3) what made the patient critically ill, and
(4) the nature of the treatment and management
provided by the teaching physician.
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Critical Care and 9928X
Can Critical Care and 9928X be
Reported Together?
 Patient presents with chest pain and has a 99285
service provided. While waiting for a bed he has an
episode of hypotension and run of ventricular
tachycardia
 CPT: May report 9928x plus 99291 by same physician
on same calendar day
 CMS: CMS Transmittal 1548 specifically states:
Hospital emergency department services are not
payable for the same calendar date as critical
care services when provided by the same
physician to the same patient.
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Critical Care Documentation
When is it Critical Care?
Critical Care Documentation
 Accurate time statement always required
 Exclusive of separately billed procedures
 Document 99285 elements or acuity caveat if any potential
to be down-coded to 99284-285
 ED Course must establish medical necessity
 Should support high complexity MDM
 Include diagnostic and therapeutic interventions performed
and/or considered even if no positive response
 Serial assessments
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When is it Critical Care
 Is it CC?
 Disposition may help as far as suggesting
that CC should be considered:
 ICU admit
 Direct to OR
 Death in the ED
 Disposition suggesting likely not CC:
 Floor or tele admit
 Discharged home
When is it Critical Care
 Documentation suggesting may not be CC
“NAD”
Normal VS
“Resting comfortably”
Minimally documented and/or benign ED
Course that does not support medical
necessity
 Psych
 Maybe: High risk presentation with
subsequent r/o of critical illness/injury




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When is it Critical Care
 May not be CC
 Urgent call and arrival of specialist is not CC unless
substantial portion of workup and initiation of treatment
by EP
 Abnormal lab values alone do not support CC unless MDM
reflects high complexity MDM and initiation of life-saving
assessment/treatment or prevention of serious
deterioration
 Consider Medical Necessity statement if above
scenarios justify CC
Critical Care Documentation
“Medical Necessity” statement should include:
 “Organ system(s) at risk is…”
 “What and why” as far as diagnostic and/or therapeutic
interventions undertaken by YOU
 Critical lab, imaging EKG findings documented and
significance addressed
 ED Course reflects frequent re-assessments and decisionmaking
 Likelihood of life-threatening deterioration
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Critical Care
 Risk management/compliance approach.
Consider reviewing:
 CC >2 hours
 Questionable medical necessity
 High (and low) frequency providers
 Importance of “Medical Necessity” note in
questionable cases
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Critical Care Examples
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Critical Care Examples
 Chest pain
 Consider CC


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EKG compatible with ischemia
Enzyme changes
Arrhythmias requiring treatment
Hypotension
Pain requiring ongoing IV NTG
Use of IV, heparin, lytics
Immediate dispo to cath lab or ICU




EKG normal and given ASA per protocol
Repeat EKG, enzymes normal
SL or topical NTG only
Dispo home
 Probably not CC
Examples
 Arrhythmias
 Consider CC
 If symptomatic (eg syncope, altered mental status/neuro signs,
chest pain, dyspnea; not simply palpitations) or significant comorbidities such as ingestion
 Treated with electricity, IV drips or multiple doses/drugs
 Probably not CC
 PAT converted in field
 Post spontaneous conversion in stable patient
 Asymptomatic AF with single bolus of diltiazem
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Examples
 Hypertension
 Consider CC
 Hypertensive emergency
 End organ(s) affected
 Brain
 Heart
 Kidney
 Treatment ongoing and typically ICU admit
 Probably not CC
 Hypertensive urgency
 Incidental finding unrelated to main problem
 May get PO or IV Rx but usually discharged or floor
admit
Examples
 Syncope
 Consider CC
 Syncope plus a significant co-morbidity. For example:






Arrhythmias such as new onset AF
Lower or UGI bleed
Significant hypovolemia
Altered mental status or seizure
Pulmonary embolism
Dispo: typically admit ICU
 Probably not CC
 “Weak and dizzy”
 No significant co-morbidity
 Simple faint
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Examples
 Seizures
 Consider CC
 Status
 Complex febrile
 Context of trauma, OD or ingestions
 ETOH or drug withdrawal
 Probably not CC
 Recurrent with noncompliant or sub-therapeutic meds
Examples
 Stroke syndromes
 Consider CC




Abnormal vital signs requiring treatment
Any airway issues
Start/consider TPA
Rapid assessment and transfer for definitive treatment at a
stroke center
 Probably not CC
 Stable patient with completed stroke
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Examples
 Dyspnea
 Consider CC






CPAP
High flow oxygen, continuous nebs and ICU admit
Altered mental status
Impending respiratory failure documented
Intubation performed or considered
CHF (usually with pulmonary edema or severe dyspnea)
 Probably not CC
 2-4 nebs or continuous nebs plus steroids and clear
 Dispo home
Examples
 Abdominal pain
 Consider CC
 Immediate dispo to OR (eg AAA, perforated viscus)
 Hemodynamic instability
 ICU admit (bowel ischemia, sepsis)
 Probably not CC
 Appy/diverticulitis: routine and admitted to floor
 Perforated appy or diverticulitis admitted to floor
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Examples
 Trauma
 Consider CC





Hemodynamic instability/abnormal VS
Possible cord injuries
Unresponsive/altered mental status
Procedures such as chest tube, intubation
Dispo to OR or transfer to Trauma Center
 Probably not CC
 Mechanism alone in alert patient w/o complaints
 Isolated extremity injuries w/o neurovascular compromise
Examples
 Ingestions
 Consider CC
 High lethality agent requiring intervention or close monitoring
 Seizures, coma, arrhythmias, hypotension
 Probably not CC
 Benign overdose with watchful waiting
 Severe allergic reactions
 Consider CC
 Stridor, wheezing. hypotension
 IV epi or pressors
 Probably not CC
 SubQ epi and/or IV steroids and clears
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Examples
 Metabolic
 Consider CC
 Most admitted DKA and/or other metabolic acidosis admitted
to ICU
 Hyperosmolar states (eg coma)
 Probably not CC
 Mild DKA treated in ED and DC’d
Examples
 Fluid and electrolyte abnormalities
 Consider CC
 Abnormal EKG
 Symptomatic (eg confusion, muscle weakness)
 Requires IV treatment
 Documentation of a critical value
 Comment and/or treatment
 Emergent dialysis required
 Acute renal failure
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Examples
 Sepsis
 Consider CC
 Sepsis bundle management (central line, elevated lactate)
 ICU admit
 Immunocompromised patient
 Transplants/cancer patients
 Most infectious disease admits to ICU
 Pneumonia, encephalitis, meningitis, endocarditis
 Pediatric dehydration
 Consider CC
 Any shock-like state
 Altered mental status
Examples
 Environmental
 Consider CC
 Hypothermia: either PLUS another problem or more
than passive external re-warming
 Lightening strike
 CO with signs/symptoms and HBO treatment or
emergent transfer
 Psych
 Consider CC
 Delirium or organic cause identified plus ICU admit
 Probably not CC
 Agitation/pure psych
 Suicide assessment
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CC for Dummies

Before documenting CC, ask yourself two questions:
1. Was patient admitted (based on medical necessity) to ICU or
immediate dispo to OR?
 If yes: strongly consider CC
 If no: is it really CC?
 If no (and you think it is CC): consider a Medical
Necessity note
2. Will the patient die or deteriorate (soon) if you don’t do
something (quickly)?
 If yes: document CC time
 If no: is it really CC?
 If no (and you think it is CC) : consider a Medical
Necessity note
Questions
rparker@acep.org
847-712-3491
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