Critical care documentation

Background

• Delivery of critical care is common in the ED setting.
• Multiple components must be satisfied and appropriately documented in the medical record when delivering critical care in the ED.

Elements of Critical Care Time

• Critical illness or injury = illness or injury that impairs one or more "one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”
• Critical care services = direct medical care for the patient that involves “high complexity decision making to assess, manipulate, and support vital organ system failure.”
  • CMS additionally mandates that for medicare patients, "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition".
• Time = total time spent evaluating, managing, and providing care to a critically ill patient. Does not have to be continuous. Includes direct patient care at bedside as well as time spent reviewing test results, discussing the case with consultants or family members, and documenting in the patient's chart.

Time Calculation

• Time spent in critical care activities must exceed 30 minutes in order to bill for critical care time.
  • CPT Code 99291 is used for the first 30-74 minutes of critical care time
  • CPT Code 99292 is used for additional blocks of time of up to 30 minutes beyond the first 74 minutes of critical care time
• Must document either a specific time or, e.g., "in excess of 30 minutes".
• Calculated time must exclude all separately billable procedures
  • These include (but are not limited to): central line or transvenous pacemaker placement, chest tube placement, endotracheal intubation, CPR.

Sample Documentation

Critical Care Procedure Note

Authorized and Performed by: MD Name

Total critical care time: Approximately 36 minutes

Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient's response to treatment; frequent reassessment; and, discussions with other providers.

This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time.

Please see MDM section and the rest of the note for further information on patient assessment and treatment.

Common Clinical Conditions Consistent with Critical Care

Must be first diagnosis

• Acidosis w/ aggressive management
• Acute Coronary Syndrome (ACS-possible MI) w/ progressive pain management
• Active bleed with admit to OR
• Anaphylactic shock
• Angina, unstable, aggressive management
• Atrial fibrillation w/ tachycardia not responding immediately to treatment
• Asthma, aggressive treatments/frequent monitoring
• Comatose/unconscious, unknown cause at presentation
• COPD/CHF severe exacerbation
• Dehydration w/ significant metabolic/ chemistry changes
• Head injury, severe, unresponsive
• Hyperkalemia w/ insulin/bicarb treatment
• Hypernatremia w/ mental status change
• Overdose, aggressive treatment, lavage or acute vital sign changes
• Pneumothorax w/ at least mild/moderate respiratory distress
• Pulmonary edema or emboli
• Rapid heart rate requiring IV therapies and/or close monitoring in ED
• Seizure, new onset or w/ disorder hx, postictal w/ intensive drug management
• Sepsis/septicemia w/ hypotensive management
• Severe bleeding requiring transfusion
• Shock-unresponsive patient
• Status Asthmaticus – defined as patient’s inability to respond during an asthma attack
• Status Epilepticus
• Stroke, acute, w/ paralysis not just parasthesia
• Subdural, subarachnoid, bleeding into the brain
• Suicidal ideation, clear & immediate threat, requiring chemical/physical restraints
• Trauma, altered consciousness, life or limb threatened
• Unstable vital signs

External Links

• https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Critical-Care-FAQ/

References

Authors

Ross Donaldson, Jonathan Osgood, Michael Holtz