Critical Care Coding Guidelines

99291 = First 30-74 minutes of care

99292 = Each additional 30 minutes of care
CPT denition of critical care is "there is a high probability
of imminent deterioration in the patient's medical
condition"
Typical HPI, ROS and other documentation elements do
not apply. Critical care is the only time based code in the
ED.
Examples: chest pain w/nitroglycerin, severe asthma,
pneumonia, CHF, severe dehydration, renal failure
E/M Level 99281
99282/
99283
99284 99285
History & Exam
Problem
focused
Expanded
problem
focused
Detailed
Comprehen-
sive
History HPI
Brief
(1-3 elements)
Brief
(1-3 elements)
Extended
(4+ elements)
Extended
(4+ elements)
ROS N/A
Problem
pertinent
(1 system)
Extended
(2-9 systems)
Complete
(10+ systems)
Past family/
social history
N/A N/A
Review of at
least 1 area
Review of at
least 2 areas
Exam
Limited to
affected body
area or
organ system
Limited to
affected area
and related
organ systems
Extended or
related organ
systems
8 or more
organ
systems
You must have 2 of 3 MDM criteria
Medical
decision
making
straightforward
low complexity
low complexity
moderate
complexity
high
complexity
Number of
diagnostic
and/or mgmt
options
minimal limited multiple extensive
Amount of
complexity
and data
minimal limited moderate extensive
Risk of
complications
minimal low moderate high
O b s e r v a t i o n G u i d e l i n e s W h a t m u s t b e i n c h a r t ?
1 . N o t a t i o n o f t h e t i m e o f i n i t i a l e x a m / t i m e o f O B S o r d e r s .
2 . P r o v i d e a s u p p o r t i n g n o t e , s u c h a s O B S w i l l b e
p e r f o r m e d t o r u l e o u t n e e d f o r a d m i s s i o n ( R / O
n e u r o d e c i t ( E T O H ) , i s c h e m i c b o w e l ( A B D p a i n ) , o t h e r
t o x i c e f f e c t s ( o v e r d o s e ) .
3 . R e - e x a m s n e e d t o b e d o c u m e n t e d w h e n t h e y a r e d o n e .
4 . D i s c h a r g e n o t e s u m m a r i z i n g O B S r e v e a l e d p a t i e n t
c o u l d b e d i s c h a r g e d .
K e y P r o c e d u r e N o t e :
P T h a s / h a s n o f a m i l y h i s t o r y o f ( x x x ) . O B S E b e g u n
a t ( t i m e ) a n d w a s n e c e s s a r y i n o r d e r t o d e t e r m i n e
( n a m e t h e R / O t r e a t m e n t / D X / m a n a g e m e n t d e c i s i o n ) .
U p o n r e e v a l u a t i o n , O B S r e v e a l e d t h a t t h e P T s h o u l d b e
( a d m i t t e d / d i s c h a r g e d ) w h i c h w a s d o n e a t ( x x x ) .
M e d i c a r e r e q u i r e s a t l e a s t 8 h o u r s o f O B S t i m e .
M e d i c a i d r e q u i r e s a t l e a s t 4 h o u r s o f O B S t i m e .
O B S L e v e l
9 9 2 3 4 /
9 9 2 1 8
9 9 2 3 5 /
9 9 2 1 9
9 9 2 3 6 /
9 9 2 2 0
9 9 2 1 7 / D i s c h a r g e * * u s e w i t h 9 9 2 1 8 - 9 9 2 2 0 * *
H i s t o r y & E x a m
D e t a i l e d o r
c o m p r e h e n s i v e
C o m p r e h e n s i v e C o m p r e h e n s i v e
H i s t o r y H P I
E x t e n d e d
( 4 + e l e m e n t s )
E x t e n d e d
( 4 + e l e m e n t s )
E x t e n d e d
( 4 + e l e m e n t s )
R O S
E x t e n d e d
( 2 - 9 s y s t e m s )
C o m p l e t e
( 1 0 + s y s t e m s )
C o m p l e t e
( 1 0 + s y s t e m s )
P a s t f a m i l y /
s o c i a l h i s t o r y
R e v i e w o f a t l e a s t
1 a r e a
R e v i e w o f a t l e a s t
2 a r e a s
R e v i e w o f a t l e a s t
2 a r e a s
E x a m
E x t e n d e d o r 8
o r g a n s y s t e m s
8 o r m o r e
o r g a n s y s t e m s
8 o r m o r e
o r g a n s y s t e m s
Y o u m u s t h a v e 2 o f 3 M D M c r i t e r i a
M e d i c a l d e c i s i o n
m a k i n g
s t r a i g h t f o r w a r d /
l o w c o m p l e x i t y
m o d e r a t e
c o m p l e x i t y
h i g h
c o m p l e x i t y
N u m b e r o f
d i a g n o s t i c a n d /
o r m a n a g e m e n t
o p t i o n s
m i n i m a l / l i m i t e d m u l t i p l e e x t e n s i v e
A m o u n t o f
c o m p l e x i t y a n d d a t a
m i n i m a l / l i m i t e d m o d e r a t e e x t e n s i v e
R i s k o f
c o m p l i c a t i o n s
m i n i m a l / l o w m o d e r a t e h i g h
F o r c o d i n g h e l p c a l l ( 8 0 0 ) 5 1 3 - 3 0 4 4 , e x t . 2 1 1
w w w . m e d i c a l r e i m b u r s e m e n t i n c . c o m
F o r c o d i n g h e l p c a l l ( 8 0 0 ) 5 1 3 - 3 0 4 4 , e x t . 2 1 1
w w w . m e d i c a l r e i m b u r s e m e n t i n c . c o m
For coding help call (800) 513-3044, ext. 211
www.medicalreimbursementinc.com
For coding help call (800) 513-3044, ext. 211
www.medicalreimbursementinc.com
Fracture Care Coding Guidelines
ED physician must provide either restorative care or
denitive care.
If denitive care is provided, which means the same
treatment as an orthopedist would provide and follow-up
with 5 to 7 days; bill fracture code without manipulation
with -54 modier.
If restorative care is provided, which means manipulate
the bones, bill fracture code with manipulation without a
modier.
2. cut along the solid
line on all four sides
3. fold along
dotted lines
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