Coding with Confidence: Navigating Critical Care in the ED Webinar

Jeannie Dean: Today we’re going to speak about critical care. I’ll go through the definition, then some examples, and then we’ll have questions that we’ll answer at the end.

A lot of critical care gets missed in the emergency department because, as emergency room physicians, it’s things you do every day. You may not think of them as critical care, but per the definition and the coding guidelines, they would meet the critical care definition and you’d be able to code them. Up to about 40% of eligible ED critical care cases go unbilled nationally.

It’s the acuity — it’s things you manage every day, so you may not think of it as critical care when you’re managing so many different things at one time. Remember, you do not have to be at bedside the entire time to bill critical care. You count the time you’re directing toward that patient’s care and add it all up toward the end — that’s how you get your critical care time.

Jeannie Dean: Another common misconception: if the patient wasn’t admitted, how could it be critical care? It’s not about the discharge disposition. The majority of critical care patients may be admitted, but they do not have to be in order for the visit to qualify as critical care. If you’re providing lifesaving measures, or actions that could prevent organ failure or organ damage, and you stabilize the patient and they go home, it’s still critical care. It doesn’t always require extreme measures like intubation or CPR — the case examples later will show that.

Jeannie Dean: CMS’s definition of critical care is a critical illness or injury with a high probability of imminent or life-threatening deterioration. That’s the high-risk standard, and it sometimes gets confused with a level 5 visit, because that’s also a high-risk patient. The main difference is the measures and treatment you’re providing because of the probability of life-threatening deterioration of the patient or a vital organ — for example, respiratory failure, sepsis, altered mental status, or airway compromise. If a patient comes in with any of those conditions and you’re able to stabilize them so they can go home, that can still qualify as critical care, along with constant monitoring, coordination with other providers, or continuous treatments like vasopressors.

It can get confusing, because some of these presentations might look like observation or a level 5 visit. It depends on why you’re doing the interventions, and the medical decision-making and planning behind them.

Jeannie Dean: Critical care is based on time. No one expects you to sit there with a stopwatch and be exact, but it must be at least 30 minutes. I’ve had providers document 25 minutes of critical care — that documentation is correct, but it can’t be billed as critical care, even though the provider did provide critical interventions and planning for the patient.

Jeannie Dean: Once you reach 30 minutes — 30 to 74 minutes — you can bill 99291, with a statement such as “I provided 45 minutes of critical care.” You don’t have to be exact, but be as close as you can with the time. One thing to avoid: don’t let all of your notes look the same. If someone reviewed 10 or 20 of your critical care notes and saw “35 minutes” or “31 minutes” every time, you’d want to see real variation in the times documented.

Jeannie Dean: 99292 is the add-on code for 75 to 104 minutes. For Medicare, to start billing 99292 you must reach the full 104 minutes, because you have to go the full 30 minutes beyond 99291, and the time is calculated per calendar day. So if you provided 45 minutes on day one, and the care crossed midnight and continued for another 30 minutes after midnight, you could bill 99291 again on that second calendar day.

Jeannie Dean: For shared services, you may combine documented critical care time, but you must meet the 30-minute minimum, whether alone or combined. If it’s a split/shared service, you must clearly state the time and the decision-making involved, and you can also bill separately billable procedures if that time is documented separately.

Jeannie Dean: Under APP critical care rules, an APP may bill independently if they deliver and document the critical care themselves. If they’re billing under their own NPI, they must document their own separate time, and the encounter must follow split/shared guidelines to determine who bills. Overlapping time — time spent with the APP and physician together — cannot be counted twice.

Jeannie Dean: What you can count as critical care time: any bedside monitoring — direct time spent assessing or stabilizing the patient; reassessments; reviewing results such as labs, imaging, or EKG interpretations; time spent reaching out to other providers or specialists about the patient’s condition; and time spent documenting the patient’s care. Family discussions count only when the patient can participate and the discussion is about the next treatment or plan of care.

Jeannie Dean: What you cannot count: any separately billable procedure, such as intubation, a central line, or CPR. If a central line and intubation together take 15 minutes, subtract that time from your total critical care time, since you’ll bill for those procedures separately. General family updates — checking on insurance, letting the family know what’s next — do not count toward critical care time; only updates that involve the patient’s care do. Calls or coordination with other providers only count if they’re directly related to the patient’s critical illness.

Jeannie Dean: Documentation timing matters too: critical care must be documented during the encounter or immediately after. You couldn’t see another patient in between and then come back to document the earlier critical care time.

Jeannie Dean: What should a great critical care note include? No two providers write the same note, even with templates. Templated notes are a good starting point, but you don’t want a note that stays generic.

A strong example: “I provided 45 minutes of critical care for the patient in respiratory failure requiring continuous monitoring, frequent reassessments, non-invasive ventilation. Medical decision-making included coordination with the ICU, response to BiPAP, and consideration of intubation. Patient remained at risk for rapid decompensation.” That’s a good note — it states the time, describes why the patient was critical and at risk for deterioration, and shows what was assessed and why other specialists were consulted.

Jeannie Dean: Compare that to a note that just says: “I provided 45 minutes of critical care for this patient, who is critical, requiring continuous monitoring, frequent reassessment, review of labs and tests, and coordination with other specialties.” The only thing that changes on that template is the time. You want notes to be specific to the patient — explaining everything going on with that individual case.

Jeannie Dean: Time tracking works the same way across an encounter. For example: 15 minutes at bedside starting at 9:00 a.m., 10 minutes of ICU consults and reassessment at 11:30 a.m., and 10 minutes of final treatment decisions and documentation at 2:15 p.m. Totaled, that’s 35 minutes — enough for 99291.

The following cases were presented as live audience polls during the session. Poll results are included as reported.

Jeannie Dean: Case 1: Chest pain, high blood pressure. A 55-year-old presents with chest pain, described as squeezing and heavy, with shortness of breath. He’s hypertensive and tachycardic. EKG shows a STEMI. He’s given aspirin and nitroglycerin, cardiac enzymes are ordered and evaluated, and a telemedicine cardiology consult is obtained. Symptoms improve and the patient is discharged from the ED.

Poll results: 49% said yes, 51% said no. The correct answer is yes — this meets the definition of critical care. The patient was at risk of life-threatening deterioration due to possible cardiac ischemia, despite being discharged. The work of monitoring met critical care thresholds, and the provider’s high-complexity decision-making, based on clinical indicators and coordination with the cardiologist, was focused on preventing decompensation. Disposition doesn’t determine the code.

Jeannie Dean: Case 2: Pediatric airway. A 2-year-old presents with a barky cough and stridor at rest. Respirations are 45, with severe retractions and O2 at 90%. The patient receives an injection of steroids plus nebulized epinephrine, remains stridorous at rest despite treatment, and requires a repeat round of steroids and epinephrine. The patient is monitored closely for three hours, with parental discussion and education, then improves and is discharged home.

Poll results: 61.5% said yes, 38.5% said no. Yes, this qualifies as critical care. Severe stridor at rest represents a potential airway emergency, putting the child at high risk for rapid deterioration, including airway compromise. The repeated epinephrine and steroid dosing, prolonged monitoring, repeated assessments, and medication adjustments — combined with the child’s age and severity — qualify this as critical care.

Jeannie Dean: Case 3: COPD exacerbation with respiratory support. A 68-year-old presents with worsening shortness of breath and wheezing. O2 is 88% on room air. The patient receives nebulized bronchodilators, is started on BiPAP, and undergoes serial arterial blood gas testing and reassessment. The patient improves on BiPAP and is admitted to the ICU.

Poll results: 69% said yes, 31% said no. Yes, this is critical care. BiPAP is an indicator — none of these three cases involved intubation or CPR, and none had an obvious, automatic marker of critical care. The determining question is what you’re preventing: if the injection hadn’t been given to the 2-year-old, could the outcome have been life-threatening? If BiPAP hadn’t been used for this patient, could they have deteriorated? Sometimes it’s the specific medication given — ask whether, without it, there’s a high probability the patient’s condition would rapidly deteriorate.

Jeannie Dean: Case 4: Vomiting and weakness. An 80-year-old presents with vomiting and weakness for two days. She’s mildly hypotensive at 88/52, with no fever, and generally hasn’t been feeling well. IV fluids are initiated, labs (BMP and lactate) are ordered, and she’s monitored for two hours with improvement after rehydration, then discharged home.

Poll results: 24% said yes, 76% said no. Not every case of dehydration qualifies as critical care — but in elderly patients, even mild hypovolemia can rapidly lead to organ dysfunction. To support critical care documentation, the chart would need to clearly show something like acute kidney injury, lactic acidosis, or altered mental status, along with frequent reassessments and close monitoring. As documented, this case would not qualify. If the labs had come back showing lactic acidosis or AKI, or the provider had done more than routine rehydration, it could have qualified.

Summary across the four cases: the chest pain patient qualified because of cardiac risk; the pediatric patient qualified because of airway compromise risk; the COPD patient qualified because BiPAP was needed to prevent respiratory failure; and the dehydration patient did not qualify as documented — though a single abnormal lab result could have changed that determination.

Yes.

Yes, as long as you subtract the time spent on the procedure from your total critical care time.

Yes, if you’re documenting the critical care services themselves — not for routine charting.

Yes, if they’re going to bill under their own NPI.

Jeannie Dean: Myth: “If I don’t say ‘critical care,’ coders won’t bill it.” Not true. The Coronis coders supporting the ED work from a medication sheet: if certain medications were given, they review the full documentation, and if critical care isn’t reflected on the chart, they send it back and ask the provider to review. There’s a similar list for procedures — intubation, BiPAP, IPAP, and others — and for diagnoses like respiratory failure. These tools tell the coder what to look for and when to send a chart back for provider review of possible critical care.

Jeannie Dean: Myth: “If the patient improves quickly, it wasn’t critical care.” Not necessarily. Sometimes the intervention itself is what worked. A patient who comes in with an allergic reaction, receives epinephrine, and quickly stabilizes still needed that intervention — ask what would have happened without it. What matters is whether, in total, at least 30 minutes of critical care time was spent on the patient.

Jeannie Dean: Myth: “Charting time never counts.” Not true. As long as you’re documenting the critical care work itself, and not just copying down vitals, that charting time counts toward your critical care time.

Jeannie Dean: Myth: “I can just list tasks, with no need to explain why.” This goes back to templated critical care attestations that simply list out everything that could be critical care — reassessments, medication adjustments, specialist consultations — without being specific to the patient. That approach doesn’t hold up, because it can’t prove those actions were related to that specific patient’s visit.

Jeannie Dean: We always want to bill the highest level possible when it’s supported — with critical care, we never want to leave money on the table. But the first reason documentation matters isn’t billing: it’s that documentation protects the provider. It needs to be there to defend that visit if there’s ever a malpractice concern. Only after that does it support capturing the billing that’s owed, so the work gets submitted and paid.

Jeannie Dean: A complete critical care attestation needs five elements: a time statement; a description of the critical illness, specific to that patient; the complex decision-making involved; the vital organ(s) being assessed and the interventions performed, such as BiPAP or serial assessments; and the medical decision-making tying it all together — why, when you were doing all of this, it was critical care. Explaining all five clearly in the attestation demonstrates why the work was done to prevent an outcome like respiratory failure or airway compromise.