Stop Missing Out on Critical Care Billing

Stop Missing Out on Critical Care Billing

Too many doctors miss out on income because they fail to bill appropriately for critical care they are providing for their patients.


Before we begin we need to clarify exactly what meets the definition of critical care. Forget what you were taught in medical school about a code being called on a patient who is crashing in the ICU and being required to provide chest compressions. The definition we are concerned about is the one handed down annually by the American Medical Association, which is accepted by all major insurance carriers.


Critical care at a minimum occurs when any vital organ system is acutely impaired and the provider believes that, without immediate care, a high probability of deterioration of the patient’s condition exists.


Have you ever considered acute renal failure as critical care? How about hepatic failure? Respiratory failure? These are the most common organ systems that are overlooked at critical moments. Acute asthma, pneumonia, and septic shock are some of the most common diagnoses missed as opportunities to bill for critical care.


Another common mistake is assuming the service must be performed in the ICU in order to qualify as critical care. Although this is the most common department, it is not a prerequisite for billing. You can work in the ED or on the floor and provide critical care. It is also important to note that if you are in the ICU and the patient is stable or you are simply not providing care to stabilize the patient, you may only bill the appropriate E&M cpt code.


How about multiple providers? Generally speaking, two providers from the same group with the same specialty cannot bill for critical care. However, physicians often believe that if they are transferring a patient or working alongside an intensivist, they cannot bill. This is untrue. For example, if an internal medicine specialist brings their patient to the ICU intensivist and a cardiologist is called in for an emergency consult, all three may bill critical care, provided each of them administered 30 minutes of care to attempting to stabilize the patient.


So this brings us to the final issue of calculating time. What is included when calculating critical care time? The overriding principle is management of patient care. Critical care will replace any E&M you had originally planned to submit for the day. Obviously the time spent at the bedside stabilizing the patient is counted. But that doesn’t always hit the 30 minute threshold. If you are elsewhere on the floor reviewing test results or imaging studies, count it.


Ditto for any consults or discussions with medical staff.


Even the time to document the critical care services are included.


Also, if you have not considered critical care billing for unstable patients being transferred to another hospital, you are missing out on a major billing opportunity.


So how about conversations with the family? Generally speaking the answer is “no” if you are simply explaining the patient’s condition. But if you have an unresponsive patient and need to determine a patient history or are facing a DNR discussion with health care proxy, this certainly taps into the principle of managing patient care.


If your time still has not reached 30 minutes, simply bill with an E&M code.


Salus Resource Group

Salus Resource Group - Salus Resource Group is a collection of business owners and professionals that serve physicians and dentists across various disciplines.