Coding and Billing

Appropriate documentation and coding are critical for billing in the intensive care unit (ICU). Diagnoses are based on the International Statistical Classification of Diseases and Related Health Problems (e.g., ICD-9 or ICD-10). Procedures are coded based on the Current Procedural Terminology (CPT) system. Evaluation and management (E/M) services make up the vast majority of non–procedure-based care provided by physicians in the ICU environment. Critical care services (codes 99291 and 99292) represent a specific subset of the CPT codes for E/M with different requirements. Three criteria must be met to justify a critical care code. First, the physician must document that the patient is critically ill (i.e., the patient has impairment in one or more vital organ systems with a high probability of imminent or life-threatening deterioration). Second, critical care requires high-complexity medical decision making to support vital organ function and/or prevent further deterioration. Third, critical care codes are time based. The physician must document the time spent in “full attention” to the patient. Critical care can also be provided via telemedicine technologies. Reimbursement for these services requires appropriate credentialing and contracts with the hospital, as well as appropriate documentation. Hospital reimbursement is based on Medical Severity-Diagnosis Related Groups (MS-DRGs), as documented in the medical record. Based on performance, a portion of hospital reimbursement may be withheld if the rates for certain hospital-acquired conditions are too high. Accurate documentation serves to (1) provide good communication between providers, (2) justify billing, and (3) legally document what was done for the patient and why. This review contains 4 tables, and 13 references. Key words: critical care codes, evaluation and management codes, global surgical package, pay for performance