There are 3 criteria that are necessary to bill for critical care in the Emergency Room.
You must have:
A critically ill patient and
CPT defines critical care as a service that “involves high complexity decision-making to assess, manipulate and support vital system function(s) to treat single or multiple vital organ system failure and to prevent further life-threatening deterioration of the patient’s condition.”
As the provider, you must document time. This includes all time spent with the patient but did you know that you should document what orders were written and actions that were taken as part of your critical care service?
While your record may imply that the services you provided were part of your critical care service, as the old adage goes: If it was not documented, it was not done. We cannot presume that the services you provided were part of any critical care service. You may count time spent away from the patient towards your critical care time as long as you are on the floor, dealing with that patients issue. Remember, if you are dealing with another patient while you are dealing with your critically ill patient, you may not count this time towards your critical care time.
If you do not document in your record that your patient was critically ill, we do not know. Your note, as the provider, must clearly indicate this fact. For example, there are occasions that a record will not reflect the fact that a particular patient was critically ill, such as acute exasperation in an asthma patient.
Last but not least, it is possible to bill an E&M service on the same date of service as a critical care code; however, it must be earlier than the critical care is provided. An E&M service cannot be separately billed if it takes place after a medically necessary critical care service is provided to a patient.