Definition and Explanation of Critical Care Service

Definition:

Coding service for caring for a critically ill or injured patient

Explanation:

Critical care has high relative value units and payments so it’s important to know the coding rules. This article describes what can be included in the time of critical care what can’t be included, and the time thresholds for reporting critical care, which are defined differently by CPT and CMS.

CPT defines critical care this way:

“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 system function(s) to treat single or multiple 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 multiple physiologic parameters and/or application of advanced technology(s), 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 to the treatment rendered to the patient, provided that the patient’s condition continues to require the level of attention described above. ” CPT® 2025 Professional Edition. AMA, Chicago, p. 58

Pay attention to the last sentence: critical care may be billed on multiple days even if no changes are made to the treatment if the patient’s condition remains critical. This could be a patient on pressors, a patient on a diltiazem drip for afib, in severe respiratory distress or on ECMO who continues to need the treatment.