Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Yes Virginia, There Is Pediatric Emergency Department Critical Care

8/8/2014 10:38:56 PM | 0 comments


In a 2013 Acute Care Continuum Blog post at Perspectives, we discussed the issue of pediatric ED providers undervaluing their services through incomplete documentation and inaccurate use of evaluation and management (E/M) codes.

But lately in our audit practice, we've also noticed that another service, critical care (CC), appears to be underreported by providers working in pediatric EDs.

What exactly is critical care?

Current Procedural Terminology (CPT) currently defines a critical illness or injury as an illness or injury that 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 services are defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision-making of high complexity to assess, manipulate and support vital organ system failure and/or to prevent further life-threatening deterioration of the patient's condition

It's also important to note that critical care reimbursement is time-based, and that at least 30 minutes of care must be delivered to constitute CC.

So why does reimbursement for critical care matter? Well, E/M (facility-based) codes account for 80–85 percent of ED revenue. What's more, critical care is reimbursed at a rate that is 25 percent higher than E/M level 5 (the highest code for non-critical care). For these reasons, proper CC documentation and billing can improve the financial health of both general and pediatric EDs — especially given the high-fixed costs and low profit margins associated with emergency care.

To some extent, underreporting of CC by pediatric EDs is understandable, since children seldom present with the cardiovascular and respiratory problems of the older adult population. Even among adults, critical care isn't terribly common — only about 5–7 percent of Medicare reimbursements to general EDs include CC payments. And because there is no uniform coverage source for children in our country, it's difficult to estimate the number of pediatric ED patients receiving critical care.

To get a clearer picture of pediatric critical care delivery, our consulting practice audited five pediatric EDs. The table below shows the proportion of CC billed by each: 

As you can see, billing for critical care was a relatively rare occurrence. Rates ranged from .05 percent (yes, one-half of 1 percent) to 3.5 percent as a percentage of all E/M services. At times, these EDs went entire months with no CC reported at all. These are urban teaching facilities, so it seems unlikely that not one critically ill child was treated for 30 minutes during an entire month.

During our audits, we examined patient charts to determine whether E/M coding was appropriate — and whether improved clinical documentation would lead to greater billing accuracy.

In these cases, since we observed so little critical care coded and billed, we also audited for potential CC. Through this process, we identified several patients who appeared to receive critical care — but for whom no CC time was documented.

(It should be noted that during an audit, we also routinely check for over-documentation of CC based on clinical presentation. This can also be a problem, especially in all-ages EDs with a high Medicare population. However, over-documentation was rare among the pediatric EDs we audited.)

When we presented our results, our clients shared several possible reasons providers might fail to document CC when appropriate:

1. “Kids presenting to our ED are not sick enough.”

Our review of thousands of charts indicates that this is simply not the case. Many children present to the ED with severe respiratory symptoms. These are usually asthma-related, although some involve a more serious underlying disease such as cystic fibrosis. In some cases, a nebulizer treatment or two resolves the issue. But in many cases, multiple treatments are required as well as IV meds.

These kids meet two key elements of the CC definition. They are certainly in danger of “system failure," namely of the respiratory system. And they certainly require intervention and monitoring. In addition, these kids sometimes have vitals, particularly oxygen saturation, in the clinical danger zone.

Usually these patients' charts are well documented in terms of presenting problems, interventions, vitals, monitoring, etc. Yet no CC time is documented — even when this would be entirely appropriate and compliant.

Other common conditions that may necessitate pediatric CC include seizures, ruptured appendix, severe injuries and other potentially life-threatening presentations. Again, the determination depends on severity and need for intervention. And yet, one client would only document CC in cases of severe injury — emphatically not the only critical care scenario.

2. “We usually provide less than 30 minutes of critical care.”

And at times, this argument is absolutely correct. Many patients, whether adult or pediatric, are moved quickly from the ED to the ICU. In these cases, the ED provider's role is sometimes limited to assessment and admission recommendation — which may not add up to 30 minutes of care.

But more commonly, we hear arguments like, “I wasn't at the bedside for 30 minutes,” or, “I had to treat other patients as well." This indicates that the provider doesn't fully understand documentation of ED critical care.

Our experience is that education — reviewing elements that can be counted toward CC time — is always of value. According to the CPT, critical care need not be delivered continuously in order to "count," nor must the physician remain at the patient's bedside for the duration of care.

In addition to certain procedures, the following activities can be included in critical care time:

  • Reviewing test results or imaging studies.
  • Discussing a critically ill patient's care with medical staff.
  • Documenting critical care services in the medical record.
  • Time spent with family members if the patient lacks capacity to provide information, so long as the conversation bears directly on management of the patient.

To promote accurate documentation of critical care time, pediatric ED physicians might want to post these criteria somewhere in the department.

3. “I understand we must subtract procedures from CC time. We don't have time for all of that math.”

That one has an element of truth. Time spent providing separately billable services such as endotracheal intubation is subtracted from CC time. But no auditor is expecting the provider to carry a stopwatch and calculator while they are trying to save a life.  A reasonable and consistent estimation of time is acceptable.

4. “Our PA/NPs or residents often provide critical care.”

Medicare can be billed using a PA/NP provider number, and such care is reimbursed at 85 percent of the physician rate. Other payers are a mixed bag. Some don't allow enrollment of PA/NPs. When in doubt, the safest approach would be to bill for physician time.

In teaching situations, Medicare is clear that only care provided by the attending physician is counted toward critical care billing. But because there are very few pediatric Medicare patients, hospital and payer policies are often more relevant here.

The other issue is a matter of teaching approach. Certainly teaching physicians want residents to learn how to treat critical care patients. But if the attending finds that they are delivering 30 minutes or more of direct care due to either the inexperience of the resident or the severity of the patient's condition, that time should be documented.


It is reasonable to expect pediatric emergency physicians to treat fewer critical care patients than those in general EDs. However, pediatric providers should not assume that they very rarely provide critical care.  ED coding personnel can help providers by providing specific feedback and training on for charts that clinically appear to be critical care but lack appropriate time documentation. Such practices can significantly improve the department's financial health.

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