Generally, critical care refers to the direct delivery of medical care for a seriously ill or injured patient. An illness or injury to be considered critical must seriously impair one or more vital organs of the patient so that their survival rate is put at risk. This requires detailed interpretation of multiple data sources along with the application of advanced technology to manage the patient. Therefore, critical medical support requires frequent personal assessment and manipulation by a trained practitioner.
As per 2012 statistics, there are approximately 6000 ICUs in the United States, which manage about 55,000 patients each day. A 2013 study conducted at Washington University School of Public Health and Health Services (SPHHS) (published in the Academic Emergency Medicine) reports a sharp increase by nearly about 50% in ICU admissions coming from US emergency departments. A significant increase in the aging US population, mainly the baby boomer generation has created an increased demand for these services.
CCU services are usually provided in areas such as emergency care unit, coronary care unit, respiratory care unit or ICU. Specialists who manage critically ill patients in these units include critical care physicians (intensivists), mid-level practitioners, nurses, physical therapists, nutritionists, palliative care specialists, pharmacists, respiratory therapists and other specialists. These specialists will receive appropriate reimbursement only when their services are reported by utilizing accurate diagnostic and procedural codes.
CCU services comprise both treatment of “vital organ failure” and prevention of further life threatening deterioration of the patient’s condition. This is a time-based service and the billing for these depends on the total time spent on managing, evaluating and providing medical support to the seriously ill patient. The time does not necessarily need to be continuous, but it cannot include the time not devoted towards patient attention. The time spent in the following activities are counted towards critical care time –
- Time spent at the bedside with the patient
- Time spent on activities related to patient attention and observation(including review of old medical records, lab and imaging results and consulting with other physicians)
- Time spent with family (whether to acquire a history or to discuss about treatment options)
Physicians while billing for CCU services can use the following codes –
- 99291 – Critical care, evaluation & management, first 30 – 74 minutes
- 99292 – Critical care, each additional 30 minutes.
Apart from this, there are services that are often performed under critical care but can’t be billed separately. However, the time spent on these services is counted towards total CC time and these include –
- Gastric intubation – (CPT 43752, 91105)
- Blood gases, and information data stored in computers (like ECGs, blood pressures, hematologic data) – (CPT 99090)
- Interpretation of cardiac output measurements – (CPT 93561, 93562)
- Chest x-rays, professional component – (CPT 71010, 71015, 71020)
- Pulse oximetry – (CPT 94760, 94761, 94762)
- Transcutaneous pacing – (CPT 92953)
- Peripheral vascular access procedures – (CPT 36000, 36410, 36415, 36591, 36600)
- Ventilator management – (CPT 94002-94004, 94660, 94662)
Futile Treatment More in Critical Care Units – Finds a New Study
A new study reveals that providing futile treatment (prolong life without achieving a meaningful benefit for patient) in the ICU leads to considerable delays in delivering care for other ill patients who require medical attention or are waiting to be admitted in CCU beds. Futile treatment is identified by specialists as ICU care from which the patients would never receive any benefit.
The study conducted by researchers at the University of California, Los Angeles (UCLA), Health Sciences found that attention for waiting patients was delayed or compromised when ineffective treatment is being provided in a full ICU. Researchers analyzed 36 critical care physicians in five ICUs in one health system to recognize patients that the clinicians identified as receiving ineffective treatment. They made 6,916 assessments on 1,136 patients during the three-month period.
Researchers identified days when an ICU was full and when it contained at least one patient receiving ineffective cure. The total number of patients waiting for the ICU admission for more than 4 hours in the emergency department or more than one day for transfer from an outside hospital was also analyzed. The key findings of the study include –
- More than 123 patients were receiving futile treatment (464 daily assessments)
- For about 72 days (16% of days), the ICU was full and had at least one patient receiving fruitless treatment. During those days, about 33 patients were kept in emergency rooms for more than 4 hours, 9 patients had to wait for more than one day to be transferred from an outside hospital and 15 patients canceled their transfer request after waiting for more than one day.
- 2 patients died at outside hospitals while waiting to be transferred to the academic medical center ICU.
The study aimed to find out whether any limitations should be placed on using resources for treatments that physicians feel will not benefit patients. The study results are quite relevant in the US healthcare scenario and also elsewhere, given universal concerns regarding providing treatments that are non-beneficial.
CCUs play a major role in saving lives as well as prolonging the dying process due to the major advancements in medicine and technology. It is rather unfair when a patient is unable to access care because ICU beds are occupied by patients who cannot benefit from such treatment.