In the hospital outpatient coding world, we find the emergency room providing “Critical Care” services.  Having a clear understanding of the documentation and medical coding is vital to compliance and accurate reimbursement. Under Outpatient Prospective Payment System (OPPS), there are two Critical Care codes that can be assigned and reported, but only one is directly associated with specific hospital reimbursement. Now is the time to take a closer look at this medical coding area.

Hospital emergency rooms encounter patients with a wide variety of illnesses and injuries, from an earache to a life-threatening auto accident in which the individual sustains serious injuries. When the clinical situation is at a high intensity of care due to the signs or symptoms of multiple organ system failure, and/or imminent life-threatening situation, the encounter service may represent “Critical Care”. This hospital “Critical Care” may be associated with a Trauma Activation if your hospital has that designation.

There are occasions when the clinical documentation is not supportive of Critical Care due to a lack of specific documentation elements or information in the provider report or note. The documentation we will also use for Critical Care can include the “Nursing Documentation”. This documentation can support a Critical Care level of service for the hospital. In fact, under OPPS, the language states, “the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once.”

In addition, we all need to remember that all clinical documentation must be truthful and compliant. However, without such complete and specific documentation the hospital will have to assign an Evaluation and Management level 1-V code. Keep in mind that Critical Care for the provider (physician) can be given in any setting, not just the emergency room, but we are talking about the “Hospital” coding in this article, so it is the Critical Care provided in the ED or the Trauma Unit of the ED.

The Critical Care service is, “the direct delivery by a physician(s) or other qualified healthcare professional (QHP) of medical care for a critically ill/injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminent or life-threatening deterioration of the patient’s condition. It involves high complexity decision making to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition”.

Think about the associated documentation with the above statement and what it should/would include. Also keep in mind that vital organ system failure includes, but is not limited to, failure of the central nervous, circulatory, or respiratory systems; kidneys; liver; shock; and other metabolic processes.