Critical care medicine remains an integral part of the practice of anesthesiology for a number of reasons. First, many of the skills, knowledge and clinical judgment required of the anesthesiologist are essential for the care of critically ill patients. Second, the practice of critical care as a part of an anesthesiology practice provides visibility for the group and a level of credibility that is valuable in the group’s interactions with other providers. This practice ultimately reinforces the knowledge, skills and expertise of the anesthesiologist, particularly to those other providers who have limited exposure to the operating room environment.

Despite these obvious advantages, many anesthesiology departments have shied away from the intensive care unit (ICU). In large part, this is due to the significant time commitments and workforce required and the perceived lack of financial viability of critical care medicine. Although anesthesiologists who have completed their training over the past 10 years have had significant experience in the care of critically ill patients, and many anesthesiologists have completed critical care fellowship programs, the number of practices that include a component of critical care as part of their daily clinical work is limited. The primary reason for the lack of participation in the ICU is financial. Most practices do not think that critical care services are adequately reimbursed or financially viable. This impression is inaccurate. Making critical care a financially viable part of an anesthesiology practice requires knowledge of reimbursement methods, documentation of the clinical value of the services provided and a cooperative hospital administration.

Critical Care Reimbursement
The American Medical Association Current Procedural Terminology™ defines critical care as the direct delivery by a physician(s) of medical care for a critically ill or injured patient. The critical illness or injury by definition 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 codes (99291, 99292) are used to bill for most of these services. Although most critical care codes are used to bill for evaluation and management services, some other activities are “bundled” in the codes, including direct clinical services, coordination of care and communication with other providers, the patient and the family. Additional procedure codes can be billed separately as long as there is appropriate documentation of the need for the procedure and its completion.

In addition to providing documentation of the care rendered, billing for critical care services must include an indication of the total time spent in providing care to and coordinating the care of the patient. The time need not be continuous but should represent the total time spent managing the patient, usually within a 24-hour period. The reported “time” represents the time spent directly related to the patient’s care at the bedside and/or on the floor/unit as well as discussions with family members or surrogate decision-makers if related directly to the patient’s care management.

When providing critical care services in the group-practice setting, many groups think that because other providers are charging for critical care services, they cannot also bill using critical care codes. Most payers acknowledge that the delivery of critical care services is variable and allow more than one provider to bill using the same code(s). Justification of the coding, however, requires careful and complete documentation of the specific services provided, the evaluation and examination of the patient and the clinical decision-making of the physician. In addition some services can be billed using other sets of codes, including those for ventilator management or hospital visits rather than the more extensive requirements necessary for billing for critical care services.

Obviously the costs of providing care in the ICU are very high. The ICU physician must be available 24 hours a day and must be able to respond to all emergency clinical situations and the need for consultation. Providing this level of coverage is difficult since the group must have a large enough complement of providers with the skills and interest to provide critical care services. Making the delivery of critical care services cost-effective for an anesthesiology group requires a number of elements. First, the number of ICU beds must be large enough to provide a “critical mass” of patients. Usually at least 12 ICU beds are necessary to allow sufficient reimbursement for the provider and to make the services cost-effective. A smaller number of patients cannot support the critical care specialist. Even a 12-bed ICU may not be able to generate sufficient clinical income to support 24-hour coverage.

The current reimbursement methods for critical care do not acknowledge the importance of avoiding critical problems, however. Unfortunately critical care services are reimbursed primarily after the patient deteriorates clinically or a complication has occurred. For example, if the critical care provider intervenes and prevents a patient from sustaining a cardiopulmonary arrest, there is little reimbursement for the care provided (basically a hospital visit evaluation and management code). On the other hand, if the patient suffers a cardiopulmonary arrest and is resuscitated and survives, the provider can bill for the resuscitative services and all associated procedures.

Other Financial Realities
Because this reimbursement system is illogical, alternative methods for supporting many of the most important services must be provided. Many nonreimbursable services are critical to the institution and, more importantly, to patient outcome, including ICU medical direction and the continuous availability of providers with the skills and judgment to assess and intervene appropriately.

In order to lobby effectively for compensation for these nonreimbursable services, the anesthesiology group must provide evidence of the value of the service and the improved outcomes that will result. The group must document what services will be offered to the institution and patients, including medical direction, development of policies and procedures to optimize clinical care and implementation of evidence-based clinical management programs to improve outcomes. These theoretical benefits must be supported with data on outcomes, cost of care and the improved clinical services. By providing such evidence, the hospital, in part to improve patient care and in part to respond to external expectations such as the Leapfrog initiative, will often support the critical care providers for these nonreimbursed activities.

In addition to addressing all of the compensation methods for critical care services, the anesthesiology group should monitor contract terms and ensure that they address the need for and value of critical care services. The contracts should specify how critical care services are to be reimbursed, the requirements needed to demonstrate medical necessity and the documentation expectations.

By understanding the clinical value of critical care services, political advantages they represent to an anesthesiology group and the financial realities of a critical care practice, critical care medicine can be a valuable addition to any anesthesiology group and can foster a stronger relationship with its hospital administration and medical community.

Gerald A. Maccioli, M.D., is Director of Critical Care Medicine, Critical Health Systems, Inc., Raleigh Practice Center and Medical Director, Medical/Surgical Intensive Care Unit, Nutrition Support and Respiratory Therapy, Rex Healthcare, Raleigh, North Carolina. He also is ASA Alternate Director for North Carolina.

Neal H. Cohen, M.D., is Vice-Dean, School of Medicine, Professor of Anesthesia and Medicine, and President of the University of California-San Francisco Medical Group, San Francisco, California.