The 2019 ICD-10-CM guidelines are effective now and critical care services must meet specific criteria per the new guidelines. It is important for coders to know the Current Procedural Terminology, CPT, critical care criteria and communicate the documentation rules to providers.
Healthcare Business Monthly recently included an article by Shannon DeConda titled, Include 3 Elements When Reporting Critical Care Services. According to the article and the new guidelines, the provider MUST identify and substantiate all 3 conditions to appropriately report critical care services, as defined by CPT. The 3 elements are:
1. Organ Failure – the patient MUST be experiencing impairment of 1 or more vital organ systems. *Documentation should indicate what current organ system failure the patient is experiencing.
2. Imminent or Mortal Threat – the patient MUST be experiencing an episode in which imminent threat to their wellbeing exists. This means that if the provider does not intervene, the patient will not survive.
*Documentation should indicate what service was provided to intervene on the patient’s behalf AND the nature of the threat.
3. High-Level Decision Making – Per CPT, “Critical care involves a high complexity of decision – making.” This makes sense, because if #1 and #2 are happening, it is reasonable to assume the provider is making high level decisions.
It is important to understand, that providers may deliver services they consider to be critical, but they do not meet the CPT definition of critical care. can communicate the CPT definition of critical care by explaining that critical care is an episode of care, but not all care that occurs because of an episode.