QUEST Integration – Critical Care

Original Effective Date:

04/01/1999

Current Effective Date:

01/01/2015

HMSA’s Plan for QUEST Integration Members covers care of critically ill or injured patients that requires the constant attendance of the physician (e.g., cardiac arrest, shock, bleeding, respiratory failure, post-operative complications). Care should be reported by the total duration of time spent by a physician providing constant attention to a critically ill or injured patient, even if the time spent by the physician on a specific date is not continuous.

Critical care usually, but not always, is provided in a critical care area (e.g., coronary care unit, intensive care unit, emergency room).

Services Included in Critical Care

Critical care should be billed using the all-inclusive CPT codes of 99291 (for the first hour) and 99292 (for each subsequent 30 minutes), which include the following services. These services should not be billed separately.

• Evaluation and management services (emergency room visit, office visit, hospital visit, consultation, etc.)
• Endotrachial intubation
• Tube thoracostomy
• Introduction of needle or intracatheter
• Venipuncture
• Placement of catheters, percutaneous or cutdown
• Arterial puncture
• Arterial catheterization or cannulation for sampling, monitoring or transfusion; percutaneous
• Chest X-ray interpretation
• Blood gas monitoring and interpretation
• Gastric intubation and aspiration or lavage
• Cardiopulmonary resuscitation
• Temporary transcutaneous pacing
• Electrical conversion of arrhythmia
• Cardiac output measurement interpretation
• Nonpressurized inhalation treatment for acute airway obstruction
• Management of mechanical ventilation
• Continuous positive airway pressure ventilation
• ECG, blood pressures, hematologic data interpretation
• Management of dialysis
• Services on Sundays and holidays, after office hours or between 10 p.m. and 8 a.m.

Services Not Included in Critical Care

The following services are not considered critical care and should not be billed:

• Standby time awaiting diagnostic laboratory and X-ray results
• Detention time when the patient’s condition has stabilized, but the physician has made a decision to remain in attendance
• Services rendered to a patient who is in a critical care unit (e.g., intensive care) but is not critically ill as defined in the clinical indications below
• Physician’s travel time to the facility

Clinical Indications

Benefits for critical care rendered to patients are based on, but not limited to, the following clinical indications:

• Sustained hypotension with systolic blood pressure of less than 90 that requires aggressive treatment with pressers or fluid (shock)
• Acute bleeding with documented serious cardiovascular instability requiring emergency transfusion
• Cardiac decompensation with evidence of severe heart failure requiring use of supplemental oxygen, emergency placement of arterial or venous monitoring catheters, and aggressive intervention with medication
• Recurrent ventricular tachycardia or fibrillation unresponsive to lidocaine bolus and drip
• Respiratory failure requiring mechanical ventilation either by mask or ventilator for 15 minutes or longer

Claims Filing Information

Benefits for critical care are based on the time the physician spends in constant attendance with the patient. This time is gauged from the moment the physician arrives at the patient’s bedside to the time the patient’s condition stabilizes or another physician assumes primary care of the patient.

Submit with the claim a report with the following information:

• Amount of time the physician spent providing critical care
• Procedure(s) performed
• Service(s) rendered
• Patient’s condition
• Names of other physicians in attendance

Critical care should be indicated using the following procedure codes:

Separate Episodes

Benefits for separate episodes of critical care may be paid if extenuating circumstances (e.g., exacerbations of underlying conditions or recurrence of the conditions that warranted the initial provision of critical care) are documented clearly.

Revision History