Critical Care: The New Normal for Anesthesia Providers

Author: Tony Mira

With the swift-moving changes we are all facing in this national emergency, the order of the day is “improvise, adapt and overcome,” to borrow a maxim of the U.S. Marines.  This is not your mother’s flu, and we’re certainly not in Kansas anymore.  We have never seen a time like this, and we are all scrambling to implement new solutions in a rapidly shifting healthcare paradigm.

Many of you have been asked in the last few days by your clinical directors or hospital administrators to plan on scaling back your normal case load and instead take on more non-anesthesia cases.  For example, many of our clients are being asked to assist with critically ill patients, including those with the coronavirus (COVID-19).  Some of our providers have broad experience with critical care; others do not.  For those who find themselves being thrust headlong into this non-traditional role, we have provided below some helpful guidelines that address how to meet the standard of critical care and how to get paid for it.

What is Critical Care?

Critical care is defined as the direct delivery by a physician or other qualified health care professional (to include CRNAs) of medical care for a critically ill or critically injured patient.  According to the Centers for Medicare and Medicaid Services (CMS), 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.”  Furthermore, critical care involves high complexity decision-making to assess, manipulate and support vital system functions(s) to treat single or multiple vital organ failure and/or the prevention of further life-threatening deterioration in a patient’s condition.

You should remember that the presence of a patient in an intensive or critical care unit (ICU, CCU), or the patient’s use of a ventilator, does not, by itself, meet the threshold of critical care for the purpose of payment.  It’s not the patient’s location, but rather the patient’s condition that triggers an opportunity for critical care.

It’s About Time

The performance of critical care services for an individual who is aged 6 years or older is indicated by, and limited to, two time-based codes.  They are as follows:  99291 (first 30-74 minutes) and +99292 (an add-on code indicating each additional 30 minutes).  If less than 30 minutes is spent in critical care services, the provider would use the applicable evaluation and management (E/M) code—typically from the “subsequent hospital care” code set (99231-99233).

Since critical care codes are time-based, the provider would need to document the total time spent evaluating, managing and providing critical care services to a critically ill or injured patient.  This time may be continuous or in incremental time blocks.  Accordingly, you should document multiple sets of start/stop times, if applicable, and list total minutes for that day.  Be careful not to include in that time calculation those minutes spent performing separately billable procedures or services that are not directly related to critical care for that patient.

Location is also important to keep in mind when calculating time for these services, as they must be performed at the immediate bedside or elsewhere on the floor or unit.  Additionally, the physician must remain immediately available to the patient, regardless of location.  Finally, the physician cannot provide services to any other patient during the same period of time.

Another time-related component involves discussions with family members or surrogate decision-makers.  Minutes spent in such discussions can be counted toward total critical care time where both the following criteria are met:

• The patient is unable or clinically incompetent to participate in giving a history, discussion of treatment, etc.; AND
• The discussion is necessary for determining treatment decisions

A summary of any family discussion is to be documented within the medical record and should include (a) a note that the patient was unable or incompetent to participate, (b) the necessity of the discussion, and (c) any treatment decisions made as a result of the discussion.  Telephone calls to family members and/or surrogate decision makers may be counted toward critical care time provided that they meet the same criteria as described above, including location.

Bundled and Separate Services

Critical care actually bundles several services, meaning you may not bill for them separately.  These include the following:

• Interpretation of cardiac output measurements
• Pulse oximetry
• Blood gases
• Information data stored in computers
• Gastric intubation
• Temporary transcutaneous pacing
• Ventilator management
• Vascular access procedures

However, you may bill separately for the following services/procedures when performed: emergency intubation (31500), A-line placement (36620), CVP placement (36556), and Swan-Ganz placement (93503).  The progress note(s) should document that time involved in the performance of separately billable procedures was not counted toward critical care time.

A Teachable Moment

Some of our clients will no doubt be working in tandem with residents in cases involving critical care.  In such circumstances, the teaching physician must be present for the entire period of time for which the claim is submitted. Time spent teaching may not be counted towards critical care time.

As far as documentation, the teaching physician’s documentation may tie into the resident’s documentation and refer to the resident’s notes for specific patient history, physical findings and medical assessment.  However, it is the teaching physician’s “stand alone” documentation that determines whether a critical care service can be billed.

Documentation Recap

We’ve already covered several documentation requirements in the foregoing sections, but it may be helpful to recap and additionally list below those items you will need to include in your progress note to support your critical care services::

• The critical illness or injury, including the vital organ system(s) implicated (diagnoses).
• Your management and treatment services relative to the patient.
• Your time spent in critical care services (including time blocks and total time for that date of service).
• An attestation that separately billable services were not counted toward your critical care time.
• An attestation that you remained immediately available (patient’s room, same floor, nurse’s station).
• If discussion with the family/surrogates is included in your critical care time:
  • Why the discussion was necessary (patient unable to meaningfully contribute)
  • Discussion was necessary for medical decision-making
  • Medical decision was made as a result of such discussion
• Your signature.
• The date of service.
• If teaching, make sure to add the requirements listed in the teaching section, above.