Q&A: Coding when two physicians bill for critical care

May 22, 2009

Critical care is the total of care rendered by a physician within a calendar day and may be rendered by more than one physician.

A: Critical care is defined as the direct delivery of medical care by a physician for a critically ill or critically injured patient, with high probability of imminent or life-threatening deterioration of the patient's condition. Critical care is the total of care rendered by a physician within a calendar day and may be rendered by more than one physician.

However, if both physicians are within the same tax ID group and are the same specialty or subspecialty, the care the two physicians render to the patient within the calendar day is normally combined and billed under one physician's National Provider Identifier. There are few exceptions to this scenario, but if the patient received critical care early in the day, improved, and then later in the day deteriorated, some insurers have allowed a second critical care visit performed by another physician within the same group later in the day (because of a new diagnosis, for example).

Critical care is a type of service; it is not a place of service. Simply because the patient is in the intensive care unit, neonatal intensive care unit, or pediatric intensive care unit does not mean critical care codes can be used-they should be used only if the criteria are met.

The author, vice president of operations for Reed Medical Systems in Monroe, Michigan, has more than 30 years of experience as a practice management consultant, and is also a certified coding specialist, certified compliance officer, and a certified medical assistant.

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