Critical Care Time Billing Question (for the experts)

[RustedFox]

- I'm unclear as to one particular aspect of critical care time billing: just how long can and should you bill for.

Example: Two shifts ago, I took care of a snowbird couple from Canada that both had carbon monoxide poisoning (his COHb% was 19, hers was 15). I had them both sit and suck on 100% NRB facemasks for 3-4 hours while local fire/police went and secured the scene. They recovered in full, and repeat ABGs had them both around 1-2% COHb. I discharged them both home.

Can I bill for CC time for the whole time that they were just sitting and sucking on their NRBs? Since it wasn't "active management", I struck a compromise with myself and billed for about 2 hours each.

- but in general, what are the guidelines for this? Total time in department billed as CC time? Total "management time" (bedside, calls, consults, charting, etc) billed as CC time?

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[The White Coat Investor]

Management.

But there's a fair amount of variation between doctors in what they feel is reasonable. One of my partners only bills 2% or so of his patients as CC Time. Another bills 8%. They both think the other is doing it totally wrong. Huge variation. The first would argue your patient's didn't get critical care at all.

 

[RustedFox]

Management.

But there's a fair amount of variation between doctors in what they feel is reasonable. One of my partners only bills 2% or so of his patients as CC Time. Another bills 8%. They both think the other is doing it totally wrong. Huge variation. The first would argue your patient's didn't get critical care at all.

So, in your opinion (and I'm asking directly because your opinion is widely held in esteem) - what would you feel is appropriate in this case? In my conscience, I can't state that every minute of them sitting in adjacent beds on NRBs (with her giving him "that look that wives give their husbands") was active management.

 

[MSmentor018]

if they're just sucking air, maybe a small portion. but any act of reassessment, calling RT, speaking with fireman/ems, pondering why canadians are still in FL in may? definitely

I had something similar. never been here. no records. unstable GI bleed on coumadin, high INR, with atrial pacer. nobody wanted to take this pt. I documented every 10 min or so on dropping v/s, how the pt looked, my interventions, phone calls....all until the time the was stable enough for helo transfer. I had to stay past my shift for this. the billing company called and had to verify though my notes. 240 minutes.

 

[WilcoWorld]

That case is totally legit CC time, but not all of it.

You can only bill for the time you spent doing things. So if you saw 5 other patients while they were breathing O2 for 2 hours, then you shouldn't bill for that whole 2 hours.

However, you can and should bill for the 35 minutes of those 2 hours that you spent doing the initial H&P, reassessing the patient, ordering the follow up blood gas, interpreting the follow up blood gas, talking to Fire Department, AND the time you spent charting it all.

 

[da8s0859q]

However, you can and should bill for the 35 minutes of those 2 hours that you spent doing the initial H&P, reassessing the patient, ordering the follow up blood gas, interpreting the follow up blood gas, talking to Fire Department, AND the time you spent charting it all.

For whatever it's worth as a newer attending with an interest in the math and business of what we do, this sort of thing is what I do as well.

 

[e30ftw]

I would agree with WilcoWorld.

I rarely bill more than 35-75 minutes of CC, because honestly there are few things that truly require longer intensive care independent of procedures in the ED. The only time I bill more than 75 min would be for example a pt in vfib arrest who repeatedly codes over the course of 2 hrs and I couldn't dispo them because they kept coding. Thankfully that is rare..

 

[Hamhock]

Fox-

I think the variability in answers to your question shows that there is certainly not a right quantitative answer (in minutes), even if one of the posters was following you around with a stopwatch.

However, whatever time you choose to bill for this, you must have the documentation to back up all that time. Yes, your MDM, re-checks, evaluation of blood gases, communications with consultants/other providers, documentation, etc counts...but that all needs to be documented.

In that light, I think "time sucking oxygen" clearly fails the definition of critical care.

If you intubated them and sent them to the ICU where they had oxygen forced into their lungs for the next 24 hours -- decreasing their CO every second -- you the ICU doc would certainly not be able to charge for 24h critical care time, right?

HH

 

[deleted109597]

It's time spent actively working on that patient and no other. Putting in orders, standing in the room, talking to consultants, talking to fire, etc, all count.
I would argue both of them likely fall into the 30-74 minute timeframe, and no subsequent. Unless literally 4 hours of your shift was spent only dealing with those two patients and nothing else (in which case, yeah, go on with 4 hours). You certainly couldn't bill 4 hours each, because the patients weren't there 8 total hours, which is what it would take for that to occur.

 

[RustedFox]

It's time spent actively working on that patient and no other. Putting in orders, standing in the room, talking to consultants, talking to fire, etc, all count.
I would argue both of them likely fall into the 30-74 minute timeframe, and no subsequent. Unless literally 4 hours of your shift was spent only dealing with those two patients and nothing else (in which case, yeah, go on with 4 hours). You certainly couldn't bill 4 hours each, because the patients weren't there 8 total hours, which is what it would take for that to occur.

This is pretty much what I thought, too. In our EMR, I clicked the 75-100 minute "box" for each, and could do so in good conscience. However, if prevailing sentiment was "any active duration of therapy being administered to remedy critical illness", then I would have felt like I underbilled.

 

[emergentmd]

This pt is no different than an asthmatic. If you want to bill CC, I go with 30-60. No way is any ED doc spending more than 30 min actively managing this pt in a shift.

I think a case can be made that there really wasn't any critical care time. I would have spend 5 min taking a hx/physical. Checked on them a few times in a shift about 1 min each at most.

 

[deleted547339]

This is pretty much what I thought, too. In our EMR, I clicked the 75-100 minute "box" for each, and could do so in good conscience. However, if prevailing sentiment was "any active duration of therapy being administered to remedy critical illness", then I would have felt like I underbilled.

Seems reasonable. Maybe a touch high, but not crazy.

 

[deleted109597]

It's not just what your conscience says though. It's what you can prove. Billing nearly 4 hours of an 8 hour shift? That's risky, and you better have lots of documentation to that effect. 12 hours? Not as bad. I mean, I've had shifts where I billed 6 of 12 hours, but I was basically running an ED ICU. And it's not that you can't send home someone with critical care, it's just a higher audit risk.

 

[RustedFox]

It's not just what your conscience says though. It's what you can prove. Billing nearly 4 hours of an 8 hour shift? That's risky, and you better have lots of documentation to that effect. 12 hours? Not as bad. I mean, I've had shifts where I billed 6 of 12 hours, but I was basically running an ED ICU. And it's not that you can't send home someone with critical care, it's just a higher audit risk.

Glad that you said something. It was a 10 hour shift that always lasts 11 hours (yes, I can get OT), so the 3 total hours seemed reasonable. It was a complicated situation. EMS, fire/police, repeat ABGs, labs, etc.

 

[deleted109597]

Glad that you said something. It was a 10 hour shift that always lasts 11 hours (yes, I can get OT), so the 3 total hours seemed reasonable. It was a complicated situation. EMS, fire/police, repeat ABGs, labs, etc.

I mean, if you've got the documentation that you spent 3 hours, then cool. It's just tougher to get that second half hour after the first code.
The fact that there isn't a 0-30 minutes of critical care time is also annoying. I wonder what percent are 30-35 minutes? Probably something like 90%.
On edit 90% are 99291, but they don't break it down for the first 5 minutes.

How often are critical care codes billed to Medicare? Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99291 and 99292 encounters were billed and the dollar value of their services for Part B Medicare.

• 99291
  • Allowed services - 5,045,749
  • Allowed charges - $1,115,802,740.49
  • Payments - $883,570,446.70
• 99292
  • Allowed services - 434,120
  • Allowed charges - $47,655,254.17
  • Payments - $37,959,581.04

Just be aware that if they come and see that you saw another 5 patients during those 3 hours (including just computerized orders), then you might have a lot to explain.
The second half hour pays well, but not as much as seeing another patient usually.

• 99291 - work RVU: 4.50; total RVU (facility): 6.31; total RVU (non-facility): 7.75. In my state, this pays around $212 for facility and $259 for non-facility sites of service.
• 99292 - work RVU: 2.25; total RVU (facility): 3.16; total RVU (non-facility): 3.46. In my state, this pays around $106 for facility and $116 for non-facility sites of service.

 

[deleted109597]

Also, got this email today that was pretty relevant.

Things that can count towards CC time: being at the patient’s bedside, reviewing test results or imaging studies, discussing the patient’s care with medical staff, documenting in the record, time spent with other decision makers when patient is unable to make decisions, and time to perform procedures that you do not bill for separately (i.e. gastric intubation, temporary transcutaneous pacing, ventilator management, peripheral vascular access not requiring imaging modality such as ultrasound). Teaching time at the bedside and resident time at the bedside does not count towards critical care billing. Documentation MUST reflect your medical decision-making. Simply putting “CHF workup” will not be enough to support your charges. Instead, consider documenting why the patient’s presenting problem(s) are of high severity, pose a threat to their physiologic function, and what will be done to evaluate for these.

 

[The White Coat Investor]

When I bill CC time, it's usually between 30 and 40 minutes. You only need 30 to get the credit, and it's pretty easy to get 30 on anyone sick enough that they need CC time. It includes calls, charting etc. I don't bother charting anything else unless I'm in there for hours, then I claim a 75+ figure.

In this case, I don't think I'd claim CC time. I mean, a NRB? Critical care? Really? I'd have a hard time charting that with a straight face. One of my partners might claim it though! I've seen people get their COs up that high by sitting there in their apartment chain smoking.

When in doubt I claim it and let the coder/billers decide whether to really bill it or not. If I don't claim it, they can't bill it.

 

[Groove]

I think CC time is vastly under billed in our specialty. I routinely bill 7-11% each month (last month 8%) and I've never been audited. I would be highly surprised to see very many audits that couldn't be justified in an emergency department of all places. I would have absolutely no problem billing for over 75 mins in the example of CO poisoning. Don't make the mistake of associating CC time with what you perceive as "hard work" as it doesn't always equate.

 

[The White Coat Investor]

Any one ever even heard of a CC Time audit? I mean, coders and billers worry about it I suppose, but I can't actually recall a time it ever happened. I agree that docs are likely to get away with claiming a higher amount of it than they do now.

 

[decrescd]

I am always surprised how much physicians in the ed bill for critical care time. At my institution I regularly see the ed billing >100 minutes on a patient I bill 30 min in the ICU. 120 for a nrb seem ridiculous to me. I would have trouble billing beyond level 3 in the ICU for that patient. I rarely see anyone in my group bill more than 60 min in my cticu for complex patient (sp lung txp, on bivad, etc). I have to imagine Medicare is going to crack down on this in the near future.

 

[Janders]

(1) Yes, this fits the definition of critical care. Many ED docs are too harsh on themselves and unconsciously don't code things critical care that we likely should-- we see emergencies constantly. This is a patient with a high likelihood of permanent harm, who needed constant monitoring and high flow oxygen.

CPT definition: "an illness or injury that 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."
CMS adds for medicare: "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition"

That CPT is definition is reasonably lenient-- most people on a 100% NRB, or a continuous infusion of medication [not saline, but nitro gtt, heparin gtt, diltiazem gtt, levophed gtt, octreotide, etc] are going to fit that definition, for starters. I would argue your cases fit.

(2) How much time? I would personally would likely bill these 35 minutes or so. Say 5 minutes for history, 5 for initial charting, 10 minutes for cumulative reassessments, 5 minutes for reviewing their lab results and charting those, and 10 minutes for the time taken talking to consultants and police/fire. In this case I'm splitting some of those conversations since its an odd case of two patients with the same situation. I believe this would be both appropriate, believable, chartable, and defensible if it was to be audited. Of course I'm seeing other patients at the same time-- but they are in the ED 4 hours, its easy for me to get my minutes in there.

The great great majority of my cc billing is for 30-75 minutes. It is rather difficult to spend more than 75 minutes on a patient in the ED, with the above restrictions, when you remember things like intubation, central access, and other procedures DON'T count towards the clock.

I do occasionally bill for 90+ minutes of critical care-- generally these are incredibly sick patients who I do end up intubating, sedating, etc.. but they end up having a prolonged LoS in the ED due to ICU availability and/or transport availability, and I do actively titrate pressors, add drips, repeat labs, repeat chest X-rays and such for 4 hours before they get out.

 

[deleted109597]

Yes, we underbill CC.
But we shouldn't overbill the few we think are sick because we don't bill the ones who are sick. Also, it encourages you to actually take care of the sick ones instead of instantly dispo'ing them. DKA? CHF requiring CPAP? Acute MI? Acute CVA? all of these things are bread and butter.
Just because the patient goes to the cath lab doesn't mean you can't spend CC time after they leave talking to the hospitalist, or their PCP, or whomever. You chart after the codes die, but you still count that time, because you're not taking care of other patients.

 

[deleted109597]

Of note, I do find it comical that the powers that be feel that $212 is enough for stopping an acute life threat. I can't get work done on my car for that, unless you count oil changes.

 

[deleted245139]

Anyone in large receiving referral centers that deal with ICU holds?
I get several tubed and vented bleeds, pressors, the works that will be accepted to an ICU with no beds that I then manage... I bill the critical care time, but try to keep it reasonable. And yes... The bigger issue is a hospital system that accepts ICU holds to an ED...

 

[deleted547339]

I am always surprised how much physicians in the ed bill for critical care time. At my institution I regularly see the ed billing >100 minutes on a patient I bill 30 min in the ICU. 120 for a nrb seem ridiculous to me. I would have trouble billing beyond level 3 in the ICU for that patient. I rarely see anyone in my group bill more than 60 min in my cticu for complex patient (sp lung txp, on bivad, etc). I have to imagine Medicare is going to crack down on this in the near future.

You're only billing 60 minutes of CC time for your CTICU patients??? In our CTICU, it's pretty par for the course for one patient to take up a good 2-3h CC time/day. Most are 30-60, but every day there seems to be one of two that like to try to die...

 

[sum dude]

There's no reason to ever bill more than 80 minutes (tech. 76 minutes) of CC time, since 75-100 min are saem, and 35 min CC time = 74 min CC time. If they were there 5 hrs, I don't think billing 75 min is out of question, assuming you went back in room and reassessed multiple times.

 

[southerndoc]

I average 10-11%. Anything that is unstable or potential to be unstable is critical care. An acutely psychotic patient requiring ketamine can be considered critical care if it requires a significant amount of your time. Likewise, SVT, rapid atrial fib, etc.

I bill all STEMI's as critical care, but only for the time they are in the department. Sometimes that's billed as 10 minutes of critical care. This does two things: if audited, it shows you aren't gaming the system by timing everything so you get reimbursed, and it also automatically makes your chart a level 5.

Any time you bill critical care, you need to have continual reassessments. You should not bill for 40 minutes of critical care without a note every 10 minutes or so noting any changes, review of labs, etc. You need to document that you are actively involved with the patient.

There's no reason you can't bill 15% of your patients as critical care if you document well (not only reassessments, initial assessment, but also medical decision making).

We all bill critical care for intubated patients, major traumas, etc., but I also bill critical care for: hypertensive urgency requiring >1 dose of IV antihypertensive, atrial fibrillation with rapid ventricular response requiring >1 dose of diltiazem or >3 doses of metoprolol, any patient receiving alteplase (PE, strokes -- we give stroke patients alteplase like candy), pneumoperitoneum, acute psychosis requiring restraints AND heavy sedation with continual reassessments, status asthmaticus requiring >1 hour-long nebulizer of 10 mg albuterol each, >1 seizure in the department/status epilepticus without return of consciousness, etc.

 

[NinerNiner999]

How often are you billing critical care for patients you discharge? Wouldn't that seem counterintuitive to an auditor?

 

[RNR]

How often are you billing critical care for patients you discharge? Wouldn't that seem counterintuitive to an auditor?

A few scenarios that come to mind - asthma, COPD, seizures that resolve, acute agitation, etc.

 

[deleted109597]

How often are you billing critical care for patients you discharge? Wouldn't that seem counterintuitive to an auditor?

You can fix SVT. You can fix a fib with RVR.
You can fix a few things that people would die of. And sometimes they can go home. Is it something we do every day? Probably not. It's not never though.

 

[RustedFox]

You can fix SVT. You can fix a fib with RVR.
You can fix a few things that people would die of. And sometimes they can go home. Is it something we do every day? Probably not. It's not never though.

I average 10-11%. Anything that is unstable or potential to be unstable is critical care. An acutely psychotic patient requiring ketamine can be considered critical care if it requires a significant amount of your time. Likewise, SVT, rapid atrial fib, etc.

I bill all STEMI's as critical care, but only for the time they are in the department. Sometimes that's billed as 10 minutes of critical care. This does two things: if audited, it shows you aren't gaming the system by timing everything so you get reimbursed, and it also automatically makes your chart a level 5.

Any time you bill critical care, you need to have continual reassessments. You should not bill for 40 minutes of critical care without a note every 10 minutes or so noting any changes, review of labs, etc. You need to document that you are actively involved with the patient.

There's no reason you can't bill 15% of your patients as critical care if you document well (not only reassessments, initial assessment, but also medical decision making).

We all bill critical care for intubated patients, major traumas, etc., but I also bill critical care for: hypertensive urgency requiring >1 dose of IV antihypertensive, atrial fibrillation with rapid ventricular response requiring >1 dose of diltiazem or >3 doses of metoprolol, any patient receiving alteplase (PE, strokes -- we give stroke patients alteplase like candy), pneumoperitoneum, acute psychosis requiring restraints AND heavy sedation with continual reassessments, status asthmaticus requiring >1 hour-long nebulizer of 10 mg albuterol each, >1 seizure in the department/status epilepticus without return of consciousness, etc.

This. If you tell me that I can bill critical care for X-Y-and-Z, then I'm going to do it. Every time.

I'll have to get better at documenting continual reassessments, but that easy. Right now for me it's rather formulaic:

Condition X is bad.
Document one reassessment and long MDM prior to dispo.
Discuss with family.
Discuss with consultant and admitting physician.
Critical care time with MDM as to why CC is justified (threat to system, intervention, response)
30-75 mins CC time.
Kthxbye.