CPT currently defines a critical illness or injury as one 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.Critical care services are defined as a physician’s direct delivery of medical care for a critically ill or injured patient. It involves decision making of high complexity to assess, manipulate and support
vital organ system failure and/or prevent further life-threatening deterioration of the patient’s condition.
Examples of vital organ system failure include, but are not limited to:
• central nervous system failure,
• circulatory failure,
• and/or respiratory failure
CMS adds that in order to qualify as Critical Care 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”.
The following services are included in Critical Care time when performed during the critical period by the same physician(s) providing critical care and should not be reported separately:
• the interpretation of cardiac output measurements (CPT 93561, 93562)
• pulse oximetry (CPT 94760, 94761, 94762)
• chest x-rays, professional component (CPT 71010, 71015, 71020)
• blood gases, and information data stored in computers (e.g., ECGs,
• blood pressures, hematologic data-CPT 99090)
• gastric intubation (CPT 43752, 91105)
• transcutaneous pacing (CPT 92953)
• ventilator management (CPT 94002-94004, 94660, 94662)
• vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600
Any services performed that are not listed above may be reported separately.
These procedures can be billed separately. Examples of common procedures that may be performed for a critically ill or injured patient include (but not limited to):
• CPR (92950) (while being performed)
• Endotracheal intubation (31500)
• Central line placement (36555, 36556)
• Tube thoracostomy (32551)
• Electrocardiogram – routine ECG with at least 12 leads; interpretation and report only (93010)
This is not an exhaustive list of possible separately billable procedures but only serves as an example that could be reported.
This table can be found on page 24 of the 2012 CPT book published by the AMA.
It is crucial that your documentation adequately describe all interval assessments of the patient’s condition including any “impairments of organ systems” based on all relevant data available to you (i.e. symptoms, signs and diagnostic data). Be sure as well to document the rationale and timing of interventions and the patient’s response to treatment. The total physician time engaged in Critical Care service must be documented. It is recommended that the physician note that “time involved in the performance of separately billable procedures was not counted toward Critical Care time.” Failure to do so might result in the Critical Care time being reduced by payers to account for any concurrent separately billable services.
From a coding perspective, documentation that is not completely clear in outlining the critical nature of the patient’s condition will delay processing of claims as inquiries for clarification will need to be made of the provider.
Written by Wendy J Alley, CPC