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Chapter 79 laid the foundation for the essential items that form the backbone of emergency department (ED) coding, in particular the assignment of the basic 99281 to 99285 EM codes and the Medicare Documentation Guidelines. Further building on the content of Chapter 79, this chapter will address the next set of coding issues to provide the knowledge and tools necessary to lead and manage a group successfully in the complex world of coding, compliance, and reimbursement.

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Emergency physicians often undervalue their services, failing to adequately document the provision of critical care resulting in lost revenue opportunities. Critical care differs from the 9928x codes discussed in Chapter 79 in that rather than relying on bean counting documentation elements of history of the present illness (HPI), review of systems (ROS), and the like, critical care is a timed-based service.

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Defining Critical Care

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Critical care is a time-based code, which as stated earlier is different than the construct of our more familiar 99281 to 99285 codes covered in Chapter 79. Current Procedural Terminology (CPT) code 99291 describes the first 30 to 74 minutes of critical care.

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In the last several years, the clinical/coding definition of critical care has been loosened. Initially, patients had to be frankly unstable and then in later years potentially unstable. Importantly, the CPT definition for critical care now simply includes the concept that there is a high probability of imminent deterioration in the patient's condition.

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“A critical illness or injury 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 … .”1

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CPT goes on to provide the following additional detail regarding organ system failure:

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“Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.”1

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This redefining of critical care allows additional patients to meet the criteria of critical care. Patients now typically qualifying for critical care frequently include

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  • Chest pain patients that are high risk requiring sequential nitroglycerin, those with EKG changes, active angina, unstable angina, or acute MI
  • Dyspnea patients with concerning vital signs requiring aggressive interventions such as multiple nebulizer treatments, high-flow oxygen, and close monitoring, with a clinical condition such as severe asthma, pneumonia, and CHF
  • Severe metabolic derangements such as DKA, dehydration, or renal failure

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Of note, the earlier examples demonstrate that there is not a clinical requirement for pressors, intubation, or invasive monitoring.

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Critical Care Time Requirements

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In addition to meeting the definition of “having a critical illness or injury,” the physician must also deliver a minimum of 30 minutes of critical care outside of separately billable procedures. These sicker patients frequently require ...

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