Questions & Answers
Volume 23 - November 16, 2011
Critical Care 30-Minute Rule
QUESTION:
I had a quick question for you about critical care billing. As I recall from the course last fall out here in Boston, we can only bill for critical care for the time a patient is actually in the ED under our care. Is that correct?
We had a case of a psych patient who jumped off a bridge into a river, clearly high risk and critical care. The patient came to our ED and was stabilized before transfer to a tertiary care hospital. If the patient was only in our ED for 25 minutes total, with doctor at bedside the entire time, and documentation done later (when patient was in ambulance on way to tertiary), then that documentation time cannot be included to meet the 30-minute minimum for Critical Care, right?
Similarly, if a code only lasts 20 minutes, but an extra 30 minutes is taken up calling the Medical Examiner, speaking/counseling family, filling out death certificate, etc…, then only the 20 minutes while the patient is alive in the department can be counted toward critical care.
Thanks in advance for your input.
ANSWER:
You are correct. You may only bill for care while the patient's presence is immediately available to you. You don’t have to be bedside; but the patient must be available to you.
There is some thought in the coding community that the 30-minute rule is only guidance, not a hard-and-fast sort of thing; and that a case like this is within the spirit of the rule. It is also argued that 2-way communication with the rig might also be additional work that you're not getting credit for, as well as work done after the patient leaves the ED, by choice or otherwise.
I agree that these sentiments have some validity, but my view is that the 30-minute rule is well-defined and should be observed precisely. Here’s why.
The time rules are based on the concept of averaging. For example, some cases take less than an hour and others take more. In those shorter cases, you are getting paid for one full hour of critical care when you've only done 30 minutes. Plus, you win even more when you go past 60 minutes. You don't have to go to a full 90 minutes to get paid the next increment of critical care; you only need to go to the 75th minute. It seems entirely fair to me to be paid only when care exceeds 29 minutes when you consider that critical care payment is for a full hour of work.
If 30 minutes of care get you 60 minutes of payment, I don’t see the need to be paid for less than 30 minutes. It's very much under-valued by the payers and far more valuable than the amounts they come up with. Still, the timing rule seems fair to me.
So, you win some and you lose some; but with the 30-minute rule in place, the payers have already given you credit for one full hour when only 30 minutes was performed. I don't see the need to extend that to less than 30 minutes.
At the back end of these cases, there is much more work associated with a pronouncement or an admission after the patient leaves. Remember that every E/M service includes some normal pre- and post- encounter work in its RVU valuation. So, some amount of your post-encounter paperwork associated with a pronouncement has been included in the RVU work values for the critical care code.
The work done after a patient is pronounced is not actually patient care, it's administrative work. Health insurance ends when the patient is no longer alive. Insurance companies are not obligated to pay for any work done after a patient is pronounced.
Q&A with Jim Blakeman
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