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E&M code

The Basics of Billing for Critical Care Services: What Physicians May Not Know

Posted on Thu, Dec 17, 2015
The Basics of Billing for Critical Care Services: What Physicians May Not Know

By Mark J. (Jeff) Slepin, MD, MBA, FACEP, and John Coyle, DO

Documentation of professional services that reflect the cognitive (Evaluation and Management – E&M) and procedural services that providers perform is an essential activity in the day-to-day practice of emergency and hospital medicine.

Perhaps you have seen a breakdown of the acuity levels of the services that you render. Do you ever wonder why certain conditions that seemingly require less work than others are assigned the identical E&M code? Does this accurately reflect a comparable amount of work, risk to the patient, generation of Relative Value Units (RVUs – a reflection of the work performed), and revenue for the practice?

Many providers are unaware of some of the nuances of documentation, coding and billing, all of which are essential to the provider getting proper credit for the services rendered and the practice generating the appropriate revenue for medically necessary services. And, do you understand exactly how the revenues are generated to provide the compensation for the work performed?

The Basics of Billing

Getting credit for the work performed and evaluation of the risks faced by the patient are essential for professional services. Most patient encounters by ED physicians and hospitalists result in the generation of a charge for an E&M service, based on the patient’s acuity, medical decision-making, and the elements of the history and physical examination. Critical care services are performed to a greater extent than most physicians realize. So, just what services qualify for classification as “critical care?”

Critical care is defined as a physician’s direct delivery of medical care for a critically ill or unstable patient. A critical illness is one with a high probability of sudden, clinically significant or life-threatening deterioration in the patient’s condition that requires the highest level of physician preparedness to intervene urgently, including direct personal management by the physician, with life and organ supporting interventions that require frequent, personal assessments and manipulation by the physician. Withdrawal of or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration of the patient’s condition.

The following table illustrates examples of conditions and interventions that may qualify for critical care.

Critical care services require the physician’s documentation of the cumulative time spent in critical care activities and must include a minimum of 30 minutes attending to the patient, which includes more than just continuous attention at the bedside. Instead, activities considered within “critical care time” include all of the following:

  • Time spent at the bedside evaluating and managing the patient
  • Time spent on activities that contribute to the patient’s care, such as reviewing old records, laboratory results, and imaging results
  • Time spent in consultations with other physicians
  • Time spent with family, whether to obtain a history or to discuss treatment options when a patient is not able to participate; and
  • Performing any of the following services:
    • Gastric intubation
    • Interpretation of blood gases
    • Interpretation of cardiac output
    • Interpretation of chest X-rays
    • Interpretation of pulse oximetry
    • Temporary transcutaneous pacing
    • Vascular access procedures
    • Ventilator management

The services listed above cannot be billed for separately when critical care services are provided, but the time spent performing these procedures counts toward the computation of critical care time.

Why It’s Important to Report Time Spent Providing Critical Care Services

The codes for most E&M services, while associated with a usual amount of time spent in their performance in the code descriptor, don’t require the physician to report the amount of time spent (with the exception of inpatient discharge day management services and services in which counseling and/or coordination of care constitute > 50% of the encounter time). Thus, the coder can analyze the problems (diagnoses, signs and symptoms), medical decision-making complexity, and the medically necessary elements of the history and physical examination to assign the appropriate code.

In contrast, critical care service codes can only be assigned if the physician INDICATES THE AMOUNT OF CUMULATIVE TIME SPENT IN THE PERFORMANCE OF CRITICAL CARE ACTIVITIES for a patient whose clinical condition(s) and interventions also are documented and qualify for the definition of a critical illness. Critical care time excludes the time spent in the performance of separately billable procedures (such as intubation, insertion of central line, insertion of thoracostomy tube, etc.)

The Bottom Line

Analysis of the aggregate services performed by a group of providers in an EM or HM program is essential for assuring adequate staffing levels, evaluating the quality of care, and collecting revenues for the practice. In terms of revenues, funds for physician compensation are primarily drawn from these revenues from the billing of professional services following analysis of medical record documentation and assignment of E&M and procedure codes by professionally trained coders and submission of a bill to third-party payers and patients.

Whether in solo or group practice, or working with a larger practice management organization, revenue should be based on the provision and accurate documentation of medically necessary services.

Jeff Slepin

Mark J. (Jeff) Slepin, MD, MBA, FACEP, joined EmCare in 2003 as the regional medical director for EmCare Physician Services (EPS), the EmCare division that manages rural, community and other small-volume hospitals and medical centers. Dr. Slepin is the medical director of NorthStar First Response, a Virginia-based company that provides basic and advanced life support training, as well as public access defibrillation programs for private and public entities. In addition, Dr. Slepin has served as a peer reviewer in emergency medicine for the Agency for Health Care Administration in the state of Florida.

John Coyle
John Coyle, DO, is Executive Vice President of EmCare Physician Services. Dr. Coyle graduated with honors with a Bachelor of Science degree in biology with a minor in sociology from St. Michael’s College in Winooski, Vt. He earned his doctoral degree from the University of New England College of Osteopathic Medicine in Biddeford, Maine. He completed his internship at Southeastern Medical Center in North Miami (Fla.) and later joined that organization’s Department of Emergency Medicine faculty. He completed his emergency medicine residency at Philadelphia College of Osteopathic Medicine. He has held senior management positions with several emergency management companies prior to joining EmCare in 2005.