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Physician Billing Patient Services 1-800-261-0048CRITICAL CARE DESCRIPTORSDESCRIPTORS THAT HIGHLY SUGGEST CRITICAL CAREThe list below will help serve as a guideline for determining critical care charts and is not all inclusive.ConditionsKey IndicatorsEYESAcute GlaucomaVisual changes and treated aggressively (eye drops)Retinal Artery OcclusionImmediate Ophthalmology ConsultCentral Vein OcclusionImmediate Ophthalmology ConsultSigns of Aggressive Management IV anti-arrhythmics: Adenosine, Atropine, Cardizem(Diltiazem), Inderal, lidocaine, Magnesium, andSulphate Pressors: Dopamine, Epinephrine, and Dobutamine Vasodilators: Nitro Drip, Nipride, and Cardene Others: Aminophyline, Glucagon, Sodium Bicarb,Dobutamine, Propofol, and Diprivan Anti-Coagulants: Heparin, Lovenox, Integrilin, andFragmin Platelet Transfusion Fresh Frozen Plasma Prothrombin Complex Concentrate (PCC)Procedures that Highly Suggest Critical Care Tube Thoracostomy BiPAP Ventilation Transfer to a higher level of care Transfer out via helicopter Surgical Airway Defibrillation CardioversionTNK, TPA, or StreptokinaseInfusionCentral line or I.O. (Excludesroutine transfers to Pediatrics,OBS or Psychiatric)Intubation /CPR Ewald or Gastric Lavage Open Cardiac MassageLumbar puncture(i.e. Meningitis, Encephalitis) CRITICAL CARE DESCRIPTORS2015

Physician Billing Patient Services 1-800-261-0048CRITICAL CARE SERVICESCritical care is defined as the direct delivery by a physician(s) or other qualified health care professional of medicalcare for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability ofimminent or life threatening deterioration in the patient’s condition. Critical care involves high complexity of medical decision making to assess, manipulate, and support vitalsystem function(s) to treat single or multiple vital organ system failure and/or to prevent further life threateningdeterioration of the patient’s condition.oExamples of vital organ system failure include, but are not limited to: Central nervous system failure,circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical caretypically requires interpretation of multiple physiologic parameters and/or application of advancedtechnology(s), critical care may be provided in life threatening situations when these elements are notpresent. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to thepatient, provided that the patient’s condition continues to require the level of attention described above. Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service onlyif both the illness or injury and the treatment being provided meet the above requirements. Critical care isusually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatricintensive care unit, respiratory care unit, or the emergency department. Codes 99291, 99292 are used to report the total duration of time spent in provision of critical care services to acritically ill or critically injured patient, even if the time spent providing care on that date is not continuous. Forany given period of time spent providing critical care services, the individual must devote his or her fullattention to the patient and, therefore, cannot provide services to any other patient during the same period oftime. Time spent with the individual patient should be recorded in the patient’s record.oThe time that can be reported as critical care is the time spent engaged in work directly to theindividual patient’s care whether that time was spent at the immediate bedside or elsewhere on thefloor or unit.oFor example, time spent on the unit or at the nursing station on the floor reviewing test results orimaging studies, discussing the critically ill patient’s care with other medical staff or documentingcritical care services in the medical record would be recorded as critical care, even though it does notoccur at the bedside.oAlso, when the patient is unable or lacks capacity to participate in discussions, time spent on the flooror unit with family members or surrogate decision makers obtaining a medical history, reviewing thepatient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reportedas critical care, provided that the conversation bears directly on the management of the patient.CRITICAL CARE SERVICES2015

Physician Billing Patient Services 1-800-261-0048CRITICAL CARE SERVICESoTime spent in activities that occur outside of the unit or off the floor (telephone calls whether taken athome or in the office, or elsewhere in the hospital) may not be reported as critical care since theprovider is not immediately available to the patient.oTime spent in activities that do not directly contribute to the treatment of the patient may not bereported as critical care, even if they are performed in the critical care unit (participation inadministrative meetings or telephone calls to discuss other patients).oTime spent performing separately reportable procedures or services should not be included in thetime reported as critical care time.oNo individual may report remote real-time interactive video conferenced critical care services for theperiod in which any other physician or qualified health care professional reports codes 99291, 99292.oCode 99291 is used to report the first 30-74 minutes of critical care on a given date. It should be usedonly once per date even if the time spent by the individual is not continuous on that date.oCritical care of less than 30 minutes total duration on a given date should be reported with theappropriate E/M code.oCode 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74minutes.oThe following examples illustrate the correct reporting of Critical care services:Total Duration of Critical Care CodesLess than 30 minutesAppropriate E/M codes30-74 Minutes (30 min - 1 hr 14 min)99291 x 175-104 Minutes (1 hr 15 min - 1 hr 44 min)99291 x 1 AND 99292 x 1105 - 134 Minutes (1 hr 45 min - 2 hr 14 min)99291 x 1 AND 99292 x 2135 - 164 Minutes (2 hr 15 min - 2 hr 44 min)99291 x 1 AND 99292 x 3165 - 194 Minutes (2 hr 45 min - 3 hr 14 min)99291 x 1 AND 99292 x 4195 minutes or longer (3 hr 15 min - etc)99291 and 99292 as appropriateCRITICAL CARE SERVICES2015

Physician Billing Patient Services 1-800-261-0048CRITICAL CARE SERVICES 99291 – Critical care, evaluation and management of the critically ill or critically injured patient; first 3074 minutes.o 99292 – Each additional 30 minutes (list separately in addition to code for primary service).According to CMS (effective 7/1/08), routine daily updates or reports to family members are consideredbundled with critical care service. CMS states “For family discussions the physician should document:oThe patient is unable or incompetent to participate in giving history and/or making treatmentdecisions.oThe necessity to have the discussion (e.g. “no other source was available to obtain a history” or“because the patient was deteriorating so rapidly I needed to immediately discuss treatment optionswith the family”).oMedically necessary treatment decisions for which the discussion was needed and a summary in themedical record that supports the medical necessity of the discussion.Documentation Requirements The physician must document the time of Critical care of 30 minutes or greater clearly visible on the chart, thisdoes not include time to perform procedures. Document that patient is critically ill or injured and why. May not qualify for Critical care: Admission to critical care services secondary to no other bed in the hospital. Patients admitted to a critical care unit for close observation and/or frequent monitoring of vital signs.Clinical Examples in the AMA/CPT ManualEmergency Department visit for the first hour of Critical Care of a: 65-year-old male with septic shock following relief of ureteral obstruction caused by a stone 15-year-old with acute respiratory failure from asthma 45-year-old who sustained a liver laceration, cerebral hematoma, flailed chest, and pulmonary contusion afterbeing struck by an automobile 65-year-old female who, following a hysterectomy, suffered a cardiac arrest associated with pulmonaryembolus. 6-month-old with hypovolemic shock secondary to diarrhea and dehydration 3-year-old with respiratory failure secondary to pneumocystis carinii pneumonia 13-year-old with hypovolemic shock secondary to diarrhea and dehydration. 13-year-old with respiratory failure secondary to pneumocystis carinii pneumoniaCRITICAL CARE SERVICES2015

Physician Billing Patient Services 1-800-261-0048CRITICAL CARE SERVICESCritical Care: Subsequently greater than 74 Minutes and in 30-minutes increment Critical care for each additional 30 minutes of treatment provided by the physician after 74 minutes of Criticalcare has been provided. It is imperative that clear documentation of this extended period of Critical care is readily visible on the chart. Itis a recommended practice to document reasons why the provider spent over 74 minutes of Critical care.CRITICAL CARE: VITAL SIGNSUnstable VITAL SIGNS consistent with organ system failure:Adult/TeenChild 1-12 yearsInfant 0-12 months 90% on O2 90% on O2 90% on O2Respirations 6 or 30 6 or 40 6 or 60Temperature 95 F or 105 F 95 F or 105 F 95 F or 105 FHeart rate 40 or 150 60 or 150 60 or 200Systolic BP 80 230 70 60Diastolic BP 40 or 130NANA 12 12 12O2 satGlasgow Comas Scale GCSCRITICAL CARE: TRAUMA SCENARIOS (1) Unstable vital signs or preventing further deterioration Immediately to surgical suite:oRuptured liver, spleen, or esophagusoPerforated viscousoFree air or excessive blood in abdomenoTorn thoracic or abdominal aorta, pulmonary vasculature, or bronchusCRITICAL CARE: TRAUMA SCENARIOS (2) Long bone or pelvic fractures with hypotension or tachycardia Quadriplegia, paraplegia, or cord hematoma Cervical fracture with subluxation or dislocation or neurologic deficit Stab or gunshot wounds of chest, abdomen, neckCRITICAL CARE SERVICES2015

Physician Billing Patient Services 1-800-261-0048CRITICAL CARE SERVICESCRITICAL CARE: TRAUMA SCENARIOS (3) Burn care requiring burn center transfer Tension pneumothorax, large pneumothorax ( 25%) or a hemothorax with chest tube placement Angulated fracture/dislocation with skin tenting or lose of pulses Fracture requiring fasciotomy or burn with escharotomyCRITICAL CARE: TRAUMA SCENARIOS (4) Traumatic subdural or epidural hematoma and/or depressed skull fracture Universal (O-) blood or other blood products given to a trauma victim Significant trauma secondary to suicide attempt e.g. hanging or CO poisoning not simple lac repair.CRITICAL CARE: MEDICAL SCENARIOS (1) Time before and after successful CPR or 30 minutes Significant mental status change secondary to trauma or medical reason(GCS 12)CRITICAL CARE: MEDICAL SCENARIOS (2) Respiratory Failure - BiPap, CPAP, 100% non-rebreather, intubation and/or ventilator management Upper airway obstruction with stridor (severe croup or epiglottitis)CRITICAL CARE: MEDICAL SCENARIOS (3) Head trauma, drug or ETOH overdoses, status epilepticus, allergic reaction, croup angioedema, or foreignbody requiring very close observation for airway control Pulmonary embolus with therapyCRITICAL CARE: MEDICAL SCENARIOS (4) Acute STEMI or non-STEMI MI to cath lab Acute STEMI or non-STEMI MI with thrombolytic Acute coronary syndrome (ACS) requiring Heparin, Integrillin , or ReoPro CRITICAL CARE: MEDICAL SCENARIOS (5) Chemical cardioversion if CP, SOB, diaphoresis Electrical cardioversion on all patients Bradyarrhythmia requiring external or internal pacemaker (heart rate 40) Accelerated hypertension requiring multiple IV vasoactive drugsCRITICAL CARE SERVICES2015

Physician Billing Patient Services 1-800-261-0048CRITICAL CARE SERVICESCRITICAL CARE: MEDICAL SCENARIOS (6) Acute thrombotic CVA with thrombolytic or consideration of thrombolytic (if the patient is back to normal notCC) in ED Hemorrhagic CVA or subarachnoid bleed Significant dehydration, sepsis, DKA, rhabdomyolysis, or other conditions requiring IV fluid boluses: 2L IVbolus in adult or 20cc/kg in child x2CRITICAL CARE: MEDICAL SCENARIOS (7) Sepsis (Urosepsis, Septicemia) Meningitis or other severe infection with IV antibiotics Warming blanket for hypothermia (Bear Hugger) Extremity or Fournier’s GangreneCRITICAL CARE: PROCEDURES (1) Non-tunneled catheters Central lines (usually with unstable vital signs) Endotracheal intubations and/or ventilator management Thoracostomy tube (usually with unstable vital signs) PericardiocentesisCRITICAL CARE: PROCEDURES (2) Pacemaker insertion Cardioversion Cricothyrotomy Intraosseous IVCRITICAL CARE: LAB VALUES (1)Electrolytes Sodium (Na) 120 or 150 Potassium (K) 2 or 6.5 Calcium (Ca) 6 or 13 mg/dl Magnesium 1.5 or 5 meq/L Bicarbonate (CO2) 10 or 40meq/L Glucose 600CRITICAL CARE SERVICESCBC Platelet count 20,000 Hgb 7 or Hct 21ABGs pH 7.25 or 7.6 pO2 60mmHg onO2 pCO2 20 or 60 O2 sat 90% on O2Other Lactate 4 mmol/L Troponin anyelevation2015

Physician Billing Patient Services 1-800-261-0048CRITICAL CARE: IV MEDS(LIST IS NOT ALL INCLUSIVE)Abciximab (ReoPro )Adenosine/Adenocard ( 1 dose)Acetadote (N-Acetyl Cysteine), IVAggrastat AmiodaroneApresoline AtropineAtivan IM or IV (for actively seizing pt, status epilepticus or significantagitation with one dose)BrethineCalcium Chloride or Calcium Gluconate 32Cardene Cardizem ( 1 dose or drip)Corlopam CroFab D50W ( 1 dose)Diazepam for status epilepticusDiazoxideDiltiazem ( 1 dose or drip)Digibind DobutamineDopamineEnalapril ( 1 dose)Epinephrine or AdrenalinEpinehprine SQ for anaphylaxis or severe allergic reactionFenoldopanFurosemide ( 1 dose)Eptifibatide (Integrillin )EsmololGlucagonHaldol IV or IM (significant agitation with one dose)Haldol IV or IM one dose and additional anti-psychotics IV or IMincluding Abilify , Geodon , Risperdal and/or Zyprexa )Heparin for PE, ACS, R/O MI or admitted chest painHydralazineHyperstat Insulin drip with or w/out initial bolusIsuprelKayexalate oral combined with IV D50/IV insulin and/or IV calcium(forhyperkalemia)Lasix ( 1 dose)Labetalol ( 1 dose) or 1 dose with an additional anti-hypertensiveLepirudin (Refludan )LevophedLidocaine (IV not subcutaneous)Lopressor (3 doses)Lorazepam (for actively seizing pt)Lovenox SQ for PE, ACS, admitted Chest pain or R/O MIMagnesium (severe pre-eclapsia, eclampsia, and Torsades de Pointes)Mannitol (Hexan )Metoprolol (3 doses)Mucomyst (N-Acetyl Cysteine), PONalaxoneNarcan Natrecor NeosynephrineNeseritideNicardipineNipride NitroglycerineNitroprussideNorepinephrineNormodyne OctreotideOxytocinPhenobarbitol for status epilepticusPhenylephrinePitocinPotassium (for K 2.5)ProcainamidePronestylPropanololReoPro Sodium ombolytics (Retavase ,TNKase )TirofibanTrandate (3 doses)TridilValium (for actively seizing pt, status epilepticus or significant agitationwith one dose)Vasotec ( 1 dose)RSI (Rapid Sequence Intubation) DrugsSuccinylcholine (Anectine )VecuroniumEtomidateRocuroniumNorcuron CRITICAL CARE SERVICES2015

Lumbar puncture (i.e. Meningitis, Encephalitis) Transfer to a higher level of care Central line or I.O. (Excludes routine transfers to Pediatrics, OBS or Psychiatric) Ewald or Gastric Lavag