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  • 1.  Weigh in on scenarios meeting critical care

    Posted 12-05-2022 08:19
    We are having some disagreements on what qualifies as critical care. Can you comment on the following scenarios and comment on if they would count as critical care billing:

    (We are a pediatric facility but these scenarios are in kids age 6 and over which qualify for the adult critical care codes)

    1. Patient with trach/chronic vent support admitted for a reason that could normally be provided for on a regular med/surg floor. Admitted to ICU b/c that is the only place that a patient on a vent can be. 
    2. Admitted to ICU after fall with subdural bleed. Alert, interactive and appropriate on room air. Admitted for frequent neuro checks.
    3. New onset mediastinal mass with partial compression of right bronchus on CT. Stable on room air and able to lie in supine position. Not starting chemotherapy until the next day. 
    4. Same scenario as #3 but staying in ICU when chemo started to monitor for tumor lysis syndrome. On room air and eating. 

    Thank you for your time.

    Randi Trope
    Physician, Pediatric Critical Care
    Stony Brook Children's Hospital
    Stony Brook NY

  • 2.  RE: Weigh in on scenarios meeting critical care

    Posted 12-07-2022 13:42
    None of these are critical care in my opinion. 
    1. This is an example of hospital policy requiring admission to the ICU and no critical intervention is being performed. Now if the patient needs titration of Oxygen beyond what they are normally on, then that would qualify for critical care. 
    2. Monitoring is not critical care. You need to actively intervene. Also you need to differentiate between admission to the ICU for nursing services and admission for critical care services. 
    3. Again no intervention, just monitoring. 
    4. Same issue no intervention, no critical care. 


    David Carpenter
    Co-Director Quality and Patient Safety Emory Critical Care Center
    Emory University Hospital
    Atlanta GA

  • 3.  RE: Weigh in on scenarios meeting critical care

    Posted 12-07-2022 15:44
    This is a really interesting discussion though and one that comes up frequently. As David mentioned, I'm not sure any of these are critical care except maybe the last one if I add some more details to it.

    1. CMS has stated in transmittal 1548 that this is not critical care (link below)
    2. Again, in transmittal 1548 it states frequent monitoring of vital signs it of itself is not critical care
    3. Same as above
    4. I think this one might have nuisance to it. If you are monitoring for tumor lysis syndrome you may have frequent lab draws that you must interpret, making decisions on chemotherapy regimen, managing electrolytes, etc, it could possibly be considered critical care but again, as David mentioned if nothing is completely normal, then it probably isn't critical care.

    The main reason for the last point is that critical care is not just the treatment of instability but also the prevention of further life threatening deterioration so if you are doing work to prevent them from being unstable with say hyperkalemia, my opinion is that you could argue it was critical care time.

    Here is that resource, the helpful stuff starts around page 13:

    Love to hear any other thoughts out there on this though as I know I've had lots of conversations with colleagues about this as well.

    Nitin Mehdiratta
    Duke University Medical Center
    Clinical Operations, Division of Critical Care
    Durham NC

  • 4.  RE: Weigh in on scenarios meeting critical care

    Posted 12-07-2022 16:34
    I don't know if the difference is peds vs adult,  it we routinely bill critical care for 2 and 3. Definitely not 1. Probably not 4 unless inordinately high tumor burden or a significant electrolyte abnormality pre chemo. I have never seen a rejection due to lack of intervention and we bill 7 different state Medicaid programs as well as multiple private insurance companies. I wonder if that is something Medicare is more focused on. Chris

    Christopher Newman, PA-C
    University of Colorado School of Medicine
    Aurora CO