• Thomas Maher

Medical Coding for Critical Care in the Emergency Department: Part 1: What Constitutes Critical Care

Emergency medicine physicians are trained to assess patients and make split-second, life-saving decisions, but documenting and coding those encounters can be complex, tedious and time-consuming. Because the relative value units (RVUs) for critical care services are high, the financial implications for physicians and their employers are significant. High RVUs also attract increased scrutiny from payers and auditors; therefore, accurate coding and documentation are imperative.

In this two-part series we’ll cover crucial elements related to critical care documentation and coding: 1.) a thorough understanding of the definition of critical care, and 2.) the documentation of critical care services and provider time in the Emergency Department.

Critical care is defined as the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. 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.

According to CMS and other payers, critical care must be medically necessary and reasonable, and is a service that encompasses both treatment of “vital organ failure” and “prevention of further life-threatening deterioration of the patient’s condition.”

Critical care involved high complexity decision making to assess, manipulate and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.

Examples that would meet the criteria for critical care include but are not limited to the following:

  • Central nervous system failure

  • Circulatory failure

  • Shock

  • Renal, hepatic, metabolic, and/or respiratory failure

Another determining factor involves the full attention of the provider. For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time. This time can be spent at the immediate bedside of the patient or elsewhere on the floor of the unit, so long as the physician is immediately available to the patient.

Knowing the definition of “critical care” is a key factor that directly impacts accurate and timely reimbursement for physicians and their practices. In Part 2 of this series, Provider Time and Documentation, we will summarize the numerous documentation and coding rules and requirements related to provider time.

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