How Do I Bill For Critical Care Services? What is Critical Care Service?

Critical Care is the direct care of the provider rendered to

Many times when a person has been severely injured they will be placed in the critical care unit of a hospital. This unit is designed for those people that are looking at a fatal condition or illness. These people require constant care around the clock.

The people who work in a critical care unit are considered to be the “angels” of the medical world. The people, who have devoted their lives to taking care of these ultra-sensitive patients, have made a commitment to providing care to those that are in a critical care situation.

Many of the patients consist of either people that are facing a terminal illness or have had some sort of trauma that requires special attention be given to their medical issues. These patients are often times given a low chance at recovery, but the nurses that work this unit see things in a different way, they see each patient as a chance at survival and renewal of life.

Beyond the care that they provide the patients, there is the human side that is often times shown to the family of these patients. Many times the families feel like there is no one there for them when they need someone. The nurses that work a critical care unit have a way of listening to a person and letting them know they are not alone in this issue.

This reassurance can often times be comforting to a person when they need it the most. It is the job of these nurses to be there both for the patient and the family. There have been a lot of changes that have come to the critical care unit since the early days in the 1920’s.

Today many critically injured patients are given a better chance at survival given the advancements that have been made in the world of medicine. There was a time when a person that was admitted to one of these units was not expected to recover.

There is a lot more of training that one of these nurses will need to go through. The reason behind this is due to the fact that a nurse in the critical care unit has to be in a position to provide extra care than what a standard nurse is used to. There is a longer training and certification period that is required for these nurses.

These nurses are also a vital part of an emergency room. They are often times the first ones that come across a trauma case in the ER. These nurses and staffers have a special ability, due to their work in critical care, to address the unique challenges of the ER and its patients.

As long as there are critical care patients, there will be a need for trained people to work these units. There will continue to be advancements in medicine that will help in the recovery process. This will lead to a person being able to recover from these life threatening situations and as a result will allow them to leave the hospital after making a full recovery.
a critically ill or injured patient who requires exclusive attention of the physician. This means a full attention of the physician to the injured or critically ill patient.

Critical Care services will require full personal management by the physician. It is an intervention with life and vital organ systems’ critical condition, life threatening and deterioration. It requires the physician’s full assessment and manipulation to prevent further life threatening deterioration in the patient’s condition.

Critical Care involves High Complexity in Medical Decision Making to assess and manage the life threatening, clinically impaired and injured patient. Vital organs such as but not limited to: central nervous system failure, circulatory system failure, shock, renal, hepatic, metabolic or respiratory system failure.

Critical Care is NOT necessarily rendered in the ICU or CCU. Critical care is always based on the patient’s condition as described above. Therefore, a stable patient in an ICU or CCU is not always a critical care service.

The rendering physician must devote his full attention on the patient and must not be interrupted by seeing other patients.

99291 – Critical Care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes

99292 – each additional 30 minutes (in conjunction with 99291)

The following procedures services are bundled in reporting Critical Care Services and are not billable during the critical care service provided on the same day by the same physician:

1. Interpretation of the Cardiac Output Measurements (93561, 93562)

2. Chest X-rays (71010, 71015, 71020)

3. Pulse Oximetry (94760, in computers ECGs, blood pressure, hematologic data (99090)

4. Gastric Intubation (43752, 91105)

5. Temporary Transcutaneous Pacing (92953)

6. Ventilatory Vascular Access Procedures (3600, 36410, 36415, 36540, 36600)

Medical Necessity Documentation:

Proper documentation must be recorded on the patient’s records and proof of medical necessity why Critical Care Service is rendered.

Illustration on how to bill Critical Care Service:

Less than 30 minutes

Use the appropriate E/M Code

30 min to 1 hr and 14 min (30-74mins) – 99291 (1 unit)

1 hr 15 min to 1 hr 44 min (74-104 mins) – 99291 (1 unit)

+99292 (1 unit)

1 hr 45 min to 2 hr 44 min (105-134 mins) – 99291 (1 unit)

+99292 (2 units)

Modifier 25 and Modifier 24 can be used to bill with Critical Care Services codes (be guided with other procedures which are bundled with Critical Care Services – see above).

For more references: Consult your CPT code books. The National Correct Coding Initiative (NCCI) and third party payer payment policies and guidelines

Categorising Critically Ill Patients by Critical Care Nurses

Critical care nursing is the delivery of specialised care to critically ill patients or patients with the potential to become critically ill – that is, those who have or are susceptible to life-threatening illnesses or injuries. Such patients may be unstable, have complex needs and require intensive and vigilant critical care nursing. The Department of Health categorises acute hospital patient care into levels from 0 to 3:

Level 0 is normal acute ward care.
Level 1 is acute ward care with the input of critical care specialists, e.g. outreach. This may be required because of recent discharge from a critical care unit or because the patient’s condition or therapy/equipment used in their care means increased intervention is needed.
Level 2 is high dependency care for patients requiring an increased level of monitoring owing to their condition or potential for deterioration or patients with single organ failure/support. Nurse to patient ratios for this level of care are usually one nurse to two patients.
Level 3 is intensive care for patients with two or more organ failure/support or requiring mechanical ventilation. Nurse to patient ratios for this level of care are usually one nurse to one patient.

Illnesses and injuries commonly seen in patients on critical care units, either separate level 2 and 3 facilities or combined units, include:

traumatic injuries from such events as road traffic accidents, falls and assaults
cardiovascular disorders, such as heart failure and acute coronary syndromes (unstable angina and myocardial infarction [MI])
elective surgeries, such as abdominal aortic aneurysm repair and carotid endarterectomy
emergency surgeries, such as bowel perforation and neurosurgery
neurological disorders, such as hypoxic brain damage and subarachnoid haemorrhage
respiratory disorders, such as acute respiratory failure and pulmonary embolism
GI and hepatic disorders, such as acute pancreatitis, acute upper GI bleeding and acute liver failure
renal disorders, such as acute and chronic renal failure
cancers, such as lung, oesophageal and gastric cancer
shock caused by hypovolaemia, sepsis and cardiogenic events (such as after MI)

Meet the critical care nurse

They are responsible for making sure that critically ill patients and members of their families receive close attention and the best care possible.

What do you do?

Fill many roles in the hospital setting, such as staff nurses, sisters, charge nurses, nurse-educators, nurse-managers, clinical nurse specialists, advanced nurse practitioners (ANPs), nurse consultants and outreach nurses.

Where do you work?

Wherever critically ill patients are found, including:

adult, paediatric and neonatal intensive care units (ICUs) and high dependency units (HDUs), or combined critical care units caring for both level 2 and level 3 patients
coronary care units
cardiothoracic/neurosurgical/burns/liver units
accident and emergency departments
postanaesthesia/postoperative care units
general wards as part of an ‘outreach’ team (providing care to patients and education to staff caring for patients with complex care needs, potential to deteriorate or recently discharged from a critical care unit).