Tips for coding critical care scenarios

Critical care coding can be confusing for both coders and providers because of the complexity of time-based codes and multiple bundled procedures. When defining this type of service, the differences between coding for adults, pediatrics, and neonates have similar yet different guidelines.

What is critical care? The CPT Manual defines critical care as follows:  

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

Remember the following points when coding critical care scenarios: 

• Providers can render critical care during life-threatening situations in any area of the hospital. 

• Providers can render critical care to adults, children, and neonates. 

• Providers most often (but not always) render critical care in the coronary care unit, ICU, pediatric intensive care unit, respiratory care unit, neonatal care unit, or emergency care facility. 

• Providers can perform critical care over the course of multiple days. 

• Critical care usually involves treatment for one or more vital organ/system failure(s), such as the central nervous system, circulatory system, renal, hepatic, and metabolic/respiratory systems, and shock. 

• Many procedures and services are bundled into the application of critical care. 

• Critical care and other evaluation and management (E/M) services may be provided to the same patient on the same date by the same physician. 

• The CPT Manual divides codes for critical care according to patient age and total duration time that the patient spends in critical care. 

• Inpatient medical necessity is defined by a severity of illness and intensity of services that can be provided safely and effectively only to an inpatient. 

• Industry-standard medical necessity guidelines provide screening criteria for inpatient care, but physician judgment and decision-making take precedence if they are consistent with accepted professional practice guidelines. 

Editor’s note: This article is an excerpt from “The Complete Guide to Medical Necessity: JustCoding’s Training and Education Toolkit” by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC.