Critical care

Critical care is defined as the direct delivery of medical care for a critically ill or critically injured patient. It requires constant attendance and supervision by the physician providing direct management of acute, complex, potentially life-threatening situations such as:

  • high likelihood of imminent or rapid deterioration,
  • acute impairment or failure of one or more vital organ systems,
  • complex assessment and preservation of vital organ system functions, and
  • utilization of advanced medical technology.
Photo by Thinkstock
Photo by Thinkstock.

To qualify as critical care services, both the illness or injury and the treatment being provided must meet these requirements. Examples of vital organ system failure include, but are not limited to, acute neurologic events; circulatory failure; shock; and renal, hepatic, metabolic, and/or respiratory failure.

Critical care is usually given in a critical care area, such as the coronary care unit, intensive care unit, respiratory care unit or emergency department, but location is not the defining criterion. Critical care may be provided anywhere in the hospital, for example, if a patient has a cardiac arrest during a radiographic study or on a general medical unit. Similarly, critical care codes are not used for services to patients who happen to be in a critical care unit but do not require critical care as described above.

The assignment of critical care codes is based on time spent providing critical care services directly related to a particular patient, whether continuous or discontinuous, on that date. Total critical care time must be documented in the medical record. Include all time spent at the bedside and on the unit continuously available to the patient, but not elsewhere. This would include time spent on the unit reviewing records, X-rays or other diagnostic studies; discussions with other health care team members or clinicians; and any other activities directly related to that particular patient's care. Time spent with family may be counted if the patient is unable to participate. Do not include time spent off-unit, for example, in the radiology department reviewing X-rays. Also, time spent performing any separately billable services is not included in the calculation of critical care time.

There are two critical care codes: 99291 and 99292. 99291 is for 60 minutes of critical care; an additional code 99292 is added on to 99291 for each 30 minutes over the first 60 minutes. However, the next level of service is not reached until the midpoint of time associated with it. Therefore, code 99292 is not assigned until 15 minutes of critical care over 60 minutes is reached, meaning that only 99291 is assigned for less than 75 minutes. Likewise, a 99292 code will be used for each additional increment of 15 to 44 minutes (see sidebar at left for examples). Do not use a critical care code for critical care services totaling less than 30 minutes.

Other evaluation and management (E/M) services may also be provided and separately coded on the same day by the same physician, including inpatient hospital care codes (99221-99223 and 99231-99233). Certain services and procedures are considered an inherent part of managing a critically ill patient, included in the critical care codes and not separately reported when performed during the critical care period. They include:

  • interpretation of chest X-rays (71010, 71015, 71020), pulse oximetry (94760—94762), cardiac output measurement (93561, 93562) and other clinical data including that stored in electronic media (99090);
  • ventilator management (94002-94004, 94660, 94662);
  • gastric intubation (43752, 43753);
  • temporary transcutaneous pacing (93953);
  • venipuncture (36000, 36410, 36415, 36591); and
  • diagnostic arterial puncture for blood collection (36600).

Any other procedures are reported separately, such as CPR, lumbar puncture, insertion of arterial or central venous catheters and intubation. Do not include the time required for these in the calculation of critical care time.

In summary, critical care is a specific, well-defined set of services and procedures. Code assignment is based on the total time spent providing direct critical care services, whether continuous or discontinuous, but the time must be documented in the patient's record. It includes time spent at the bedside and on the unit, but not elsewhere. The calculation of time associated with critical care code assignment may seem confusing at first, but it is not difficult when the criteria are clearly understood. Additional E/M services and other procedures may be separately coded when provided but not included in the critical care time calculation.