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Inpatient vs. Critical Care Consult
Audrey E. Coaxum, CMC, CMIS, CMOM, CHI, PMI Faculty

Question:
Can you bill a 99291 instead of an inpatient consult when the consult states critical care consult?

Answer:
CPT defines critical care as the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient.

A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition. Examples of vital organ system failure include but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.

Although critical care typically requires interpretation of advanced technology(ies), critical care may be provided in life threatening situations when these elements are not present. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient’s condition continues to require the level of physician attention described above. Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

Critical care is usually, but not always, given in a critical care area, such as the coronary unit, intensive care unit, pediatric intensive care unit, respiratory care unit or the emergency care facility. Critical care services consist of several comprehensive services that include: cardiac output measurement interpretation, chest x-rays, blood gases, use of computer-stored information, gastric intubation, temporary transcutaneous pacing, ventilation management and vascular access procedures. The critical care service codes are not based on the performance of the key components of history, examination and medical decision making. Critical care service is based on the total duration of time on a given date spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time is not continuous.

The time spent with the individual patient should be recorded in the patient’s chart. Whereas a consultation, as defined by CPT, is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The written or verbal request for a consultation may be made by a physician or other appropriate source and documented in the patient’s medical record. The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated by written report to the requesting physician or other appropriate source.

A summary of consultation requirements include:
1) A consultation is an E&M service provided a physician whose opinion and/or advice regarding evaluation and/or management of a specific problem is requested by another physician.
2) The request and need for the consultation is documented in the patient’s chart.
3) The consultant’s opinion and any services ordered or performed are documented in the patient’s chart.
4) The consulting physician may initiate diagnostic and/or therapeutic services at the same or a subsequent visit.
5) The consulting physician must communicate his/her opinion and/or advice back to the requesting physician or other appropriate source by formal written report. Thus, if your provider is being asked to render his/her medical opinion on a patient that may be critically ill, you would select evaluation and management codes from the 99251 – 99255 (Inpatient Consultation Category) to bill for their services.

Response courtesy of Audrey E. Coaxum, CMC, CMIS, CMOM, CHI, PMI Faculty