Tips for Critical Care Coding

Critical care isn’t confined to the ICU anymore. 

In the latest episode of Compliance Conversations, Healthicity’s CJ Wolf talks with compliance coding expert Maya Turner about how evolving CPT^® guidance and CMS interpretations are reshaping what counts as billable time. 

From telehealth consults to physician direction during patient transport, critical care can begin long before a clinician reaches the bedside. Turner cites 2025 CPT^® language clarifying that physicians who are “immediately available” may count time spent managing patients remotely, so long as their actions directly relate to patient care. 

The two also tackle a persistent challenge: how coders and clinicians communicate. Turner emphasizes that denying claims without explanation damages trust, while teaching providers about alternative codes or documentation strategies builds stronger relationships and compliance outcomes. 

Listeners will walk away with practical insights on defending critical care minutes, identifying what’s truly billable, and fostering collaboration across the care team. 

Here is a link to the OIG audits referenced in the episode. 

You can read Maya’s book, Billable: The Revenue Cycle Professional's Guide to Branding, for more insights. 

Episode Transcript

Welcome everybody to another episode of Compliance Conversations. I am CJ Wolf with Healthicity. And today's guest is Miss Maya Turner. Welcome, Maya. 

Hello CJ. It's so good to see you again. 

Yeah, it's so good to see you. We've bumped into each other recently at some conferences, had some good conversations, and we thought, okay, we gotta instead of just talking between ourselves about these, let's let's throw it out there for the world and see what they have to say. And so, but before we get into that topic, Maya, I know you've been on the show before, but maybe just spend a couple of minutes telling us a little bit about yourself, you know, what you're doing, any upcoming projects that you're working on, and then we'll jump into our content. 

Okay. Um, and I because there's so much content to discuss, I'm just gonna try to keep this brief. Um, well, as much as I can anyway. Um, uh I'm uh my name is Maya Turner. I am with the AAPC um National Advisory Board. I have uh seven certifications that I'm very proud of. Um, and um we do a lot of work in regards to um uh creating uh the venue for coders to find their ways. Um and one of the projects that I'm very happy to announce is that I I've written a book recently called Billable, and it's called The Revenue Psycho Professional's Guide to Branding. And the reason why it's so important is for when coders are educated through the VIP program, which CJA and I are both involved with, it's important for coders to have a foundational idea of what they want to do and build on that expertise before they do anything else. And so I think this book is very important, and it's also foundational for any coder's career for them to flourish and to build and to create relationships and to know um what's good, what's not good, and the best things to go about doing uh things that are um really uh foundational in the industry. 

Yeah. And is the book already out, or is it you have a release date, or tell us a little bit about it? 

It's been out and believe it or not, it's already been listed as an Amazon bestseller. So it's really actually very cool. And I think a lot of people are lagging on, locking on to it because it really talks about things that people really don't realize are important when they're starting. Because when you're a coder, you want to be good at everything, but you have to really start at one thing before you're good at something else. So that's really important for me. Yeah. 

Well, good. Well, maybe you can uh include send us a link of where people can uh look at it and uh we'll include it in the show notes for people to check out. That's very cool. Very cool, CJ. Because you're a cool guy. Yes. Thank you. And um, you know, let's kind of let me introduce the topic a little bit. So we were at a conference recently, I was presenting on critical care, um, and some questions came up. Um and uh, you know, to kind of set the stage, you know, we all should know that there's payer policy, right? What payers allow and don't allow, and then there's CPT guidance. And sometimes in the absence of payers specifically saying something, you usually defer to the CPT uh guidelines, right? And so the question that that kind of came up had to do in critical care. But I think a lot of us understand that majority of critical care is done in the hospital, um, right? The doctors are typically in a space where those types of patients can present themselves with critical illness or injury, but not always, right? They can't what if they're out in the field and right and the doctor's on the phone? And so that was kind of the question that came up was talking about what happens when a doctor is directing critical care kind of remotely, if you will. Um is that Maya, is that how you understood it? Before I get into the questions, you kind of correct me if I misstated the scenario. 

There's a lot of there's a lot of uh terminology as it relates to how critical care is is is performed. And the gleaning factor is where it's performed, right? And I think that's where the question drove because a lot of times the physician is at the hospital floor and they're directing via vitals, they're directing via interpretation of that's being reported or electronically submitted. And so the question came is if the physician is awaiting the patient while they're in transport, can they report that time? And we heard lots of different opinions, and we were like, I don't know. And so um that's created that whole conversation that we were like, we should talk about it. And we're like, okay, so yeah, so that's kind of where that came from. Yeah. 

Yeah, and and we'll invite you as well, if you know, and that's kind of why I preface this with some payers might have policies versus CPT guidance. So if you have a comment, or if you know, in the in the links of the show notes and stuff, you'll be able to comment and that sort of thing. So if you have a comment that, oh, well, in Arkansas, this payer says X, yeah, that's great. Share that information. We want everyone to know that certain payers have certain policies. Um, but if they don't have a policy and you have some sort of guidance or knowledge from a CPT standpoint, sure, share that as well. But what we did is we kind of went back and started reading the CPT guidelines. So tell us a little bit about what your initial take on that is from this from the CPT guidelines and how you're interpreting that kind of unit floor time, if you will. 

Well, the CPT guidelines indicate that if they're awaiting and immediately available to service the patient, but it doesn't limit to where the provider can provide the critical care service. It just says immediately available. So on page 29 of the 2025 guidelines, it states codes 99291 and 99292 should be reported for the attendance during the transport or critically ill or critically injured patients older than 24 months of age to or from a facility or hospital. Um, for transport services, critically ill or critically injured pediatric patients 24 months of age or younger, see 99466 or 99467. And the issue was that while the patient is in transport, can the physician report the critical care services? And one piece of the critical care reference does not indicate the overall view of what CPT says in regards to critical care. So CJ and I were talking afterwards and we were like, Well, I paid him credit. And it was like, Well, are you? Well, I'm okay. Oh, so we kind of went into this thing and we're like, well, let's kind of see what it says. And so when I looked at uh page 29 of the CPT book, it clearly says transport to a hospital as long as they're immediately available. And I think that's what coders often misinterpret and don't give providers that work because they are intervening in a life-threatening emergency as it relates to critical care. So yeah, such a good point. 

I'm glad you found that. Um, because on the mo in the moment when I was teaching, I didn't have that at my fingertips. I couldn't recall exactly. Yeah, but we had been doing it for so long, and we're like, well, yeah, it's the way we should be showing us wrong for this medic. Yeah, it didn't feel right in our gut. And so, but that's not good enough. You have to go back and then do the research, which is what you've done. And so I we wanted to talk a little bit about that. Now, let me ask you too, because and I came back and I started to research from CMS and Medicare, and I couldn't find anything. But again, audience, if you're aware of something specific, feel free to share. We're not saying we're the law, we're just sharing what we know at this point. I couldn't find anything from CMS that would prohibit that. Have you been able to find anything? 

No, it doesn't. Um, and what's really interesting is that anything that's related to evaluation and management, CMS differs to AMA. Right. And so when you look at um the definitions that are associated in the uh um the um internet only manual, um, that is uh I believe it's chapter 12, 13. Um, I have the where is it? I have the claims processing manual. I think it's the claims processing manual, but don't hold me to it because there's so many. Oh, here it is. Yeah, claims processing manual, chapter 12, section 36, 12. And it says time spent in gauge and work directly related to the individual patient's care, whether that time is spent at the immediate best bedside or elsewhere on the floor unit may be counted towards critical care time, provided that the activities are directly related to the care of that patient. So it doesn't necessarily say that how they're related, because technically you could talk to critical care's family, the patient's family, over the phone. And so that doesn't necessarily deal with the patient, but it is related to the patient. You're delivering the care that's in relation to that situation because having that conversation with family members is part of the description of critical care services. So it does create some um some uh conversation in regards to how it's viewed. But if coders are really uh saying that you you're not on the floor, you're not getting you're really gonna have some physicians really mad at you, one, because if they're under if it even if it took under, I mean, let's just think about this. Let's kind of break this down, right? If we think about how it translates to them being transported, and it's the difference of them activating trauma, right, versus not activating trauma, that's gonna be the difference on the care that's immediately available and even cause the hospital some liability if they knew in transport that this was happening and it didn't occur the way that it should, because the physician was coordinating that care and or the patient was in transport as it relates to that service. So right. 

Well, and and to your point, if you're talking to the family, that counts towards the critical care time. Talking to family alone won't meet critical care criteria. You still have, and I just want everyone to be clear we're not saying that alone counts. We're saying assuming you meet the first definitions of critical care is one, the patient's critically ill or injured, two, you have done some sort of service that intervenes, you know, to prevent you know immediate deterioration, those sorts of things. As long as those things are met and then you've met the 30-minute limit, right? What we're saying is the time that they're spending um may also be added because what we're getting at here is um the the injury or illness happens, the physician is guiding them on their way. Once they get there, it's typically that same physician who's doing the face-to-face inter right. So this is like work that's done before they get there. And so usually in these cases, uh the physician might even see the patient multiple times during the day. And we know you add up all the critical care for that data service. So what we're saying is do you also give them credit for the X number of minutes, right, that was spent in that? And and what we're what we're finding is from a CPT standpoint, it sounds like yes. Um then I had a question you just answered was looking at the CMS manual. The other thing, Maya, that I found was I went to the um and last week, and this is gonna, I think this podcast uh from last week will be posted before this one will. We had Keisha Wilson on and we were talking about uh telehealth. 

Yes, telehealth critical care. Yes, yeah. 

After that, after that conversation, I'm like, wait, I know I'm meeting with Maya, I'm gonna go check the CMS telehealth list. Critical care is on the list. So so I know that's not the exact same thing we're talking about, but it's Medicare will pay for critical care via telehealth. Now, I know we're right in the middle of government shutdown and extensions and all that sort of stuff, but outside of that, they have in the past listed it. And so it's like, well, yeah, now that kind of makes sense to me. 

Yeah, it does. I mean, because think about it. I mean, a lot of times the transport is where it's most critical, right? Because you're reviewing, you're thinking about the ABGs, your telemetry, all of the resuscitation, you know, based upon the signs and symptoms that are presenting, right? And so because it's real-time life sustaining effort that is presented, once they get to one point, that physician's work is really that physician's work and it's legitimate. So, I mean, the fact that it almost didn't go that way or was misinterpreted, or even, you know, because a lot of times when you're new or when you're regimented in a certain way of doing things, you don't see the broader spectrum, and it becomes like, oh, this is a teaching point, or oh, wait a minute. I didn't really know that because, because, because, because a lot of people didn't really know that critical care was actually on the telehealth list. And so, I mean, okay, so the patient is on telehealth, but what if it's out of the physician who is receiving the patient? What if it's out of their scope and they have another provider who's not face-to-face, it's not on the floor. So you got to think about all of these different scenarios that come into play that you're like, oh, wait a minute. Maybe I need to rethink this. And if CMS is defaulting to AMA for guidance on ENM and critical care, then maybe should you? So, you know, it's a really interesting thing. 

So, yes. Yeah. Well, Maya, let's take a quick break and come back because this is I've got some other thoughts and questions for you. Um everyone hang everyone hang tight for a few uh for a minute here and we'll be right back. Welcome back, everyone, from the break. We've been talking um about critical care. We've been diving deep into those critical care codes. Um as we just before break, you were talking about recognizing the work of clinicians. And so, you know, one of the things that I know you're involved in is kind of changing culture, uh, helping physicians feel recognized for their work. So we've talked about what we think is included in the billable time, right? What happens when they're when we all are in agreement that something isn't billable critical care time? How do you still help the physician feel recognized for their work in that regard? Because they're thinking, look, my time is is what I'm devoting here. Um any thoughts on that? 

You know, there's a there's a lot of different thoughts on that. And a lot of times when physicians hear that they can't bill, right? It doesn't mean that they can't bill for anything. It just maybe they may not be able to build exactly what they want to build for that moment. So I think it's very important that physicians understand one, what their options are. Two, they have to understand that when it's explained and you count for certain things that are not necessarily um countable, it's a teaching moment. But again, once they hear, what do you mean? Hold on, I didn't say that the world was ending. I'm saying that you can't build for that specific thing. And because you can't bill for that specific thing, let me tell you what your options are, right? And so we have to really think about the context of how we approach um the options, right? Because if the first thing they do is, are you saying that I'm invalid with my thought process or I'm invalid with what you know what I'm thinking? No, we're not saying that you're not invalid, but the context of what you use your validity is not applicable for this particular scenario. And because of that, you want to provide the alternatives for the service that you are providing that can be built based upon what you're doing. 

Such a good point. And I think if you approach it that way consistently, you build better relationships. Because to your point, if if the first time they see you is you're coming to them saying you can't build critical care, right? Then it's like, oh, we're in a judgmental confrontation from the get-go. Rather than saying what you can't do, I'd like what you said. It's like tell them all of their options of what they can do, and then explain professionally these are the criteria that have to be met in order to build that higher level, which is critical care or whatever it is, right? Right, right. So it's all about kind of relationships and how you approach it. Are you the person of no? Because if you do that two or three times, they don't ever really want to see you because you're the person that always tells them what they're doing wrong. 

Yeah, it's like the finger in the face, right? 

Yeah, yeah, yeah. So good point. And then go ahead. Was there something else? 

I was just gonna say, you know, I've seen time and time again where precoders are so rigid about what providers can and cannot do that they don't want to hear from them anymore. And it doesn't cultivate a relationship. The goal is to be the voice of the provider, the intermediary between payer and provider clinical judgment. And you're not necessarily acting like a provider, you just want to understand the view so it's defendable, right? So think about you being a mom and your kid is being bad and you're like, oh yeah, he was bad. But you want to be able to say, well, you know, he's had da-da-da-da-da-da-da-da-da-da. And traditional, he's not, you know, so you want to be able to be that voice of reason. If it ever came up again, you're able to defend them and create a rational and an engaging conversation on why or why something didn't happen. 

Yeah. Such a good, such a good point. That's a good point of developing our professionalism and uh love that. So tell us then about you know, uh an ED evaluation and critical care on the same day, because sometimes a patient might come into the emergency room. At that moment, they might not be critically ill or injured. So you're doing an emergency department visit, it might turn into, and a lot of people are in the emergency department for three or four hours before they discharge them. And and maybe in during those three or four hours, their their status deteriorates and it might go into critical care. So tell me a little bit about that. 

Okay. So a lot of times um when you're dealing in the critical care health space, uh, CMS defines that you can bill for an additional service if they're not critical at the moment and you were called into a situation. Again, they still might be at an emergent level, but that that that threshold of which they're threatening a heart attack or they're threatening a stroke, and the the the labs and all of the diagnostics are negative into them going into the stroke. Because again, you have to think about the necessity, the the life-threatening imminent emergency. So again, you could still bill for the critical care visit as long as the secondary visit of the critical care nature comes up and it's documented, the level of deterioration, the reason that they were called, because at the end of the day, it's all about saying the story from the time that you saw them to what's happening throughout. Now, of course, if it becomes um an admission that it all is rolled into one because of the certain things. But um, again, that's uh for a letter later time. But if the physician is reporting the professional service and he's managing the emergency visit as well as the critical care, it is definitely reportable. And CMS does not have any um uh pre-regards of how it shouldn't be reportable as long as it's documented because it's a story about capturing what was imminent related to death. 

Period. Yeah. Yep. Such a such a great point. Yeah. Um, so you know, you probably do a lot of, I know you do consulting work and you have clients and then you're doing education as you already described at the beginning. So, what are some any self-audit tips for people who want to double check that their critical care minutes are defensible? Are any things that you anything that you come across regularly and and you could give tips on? 

Okay. I'm trying to, I'm not, I have nightmares of what actually happened, but I was uh uh for a very long time, for a period about 12, maybe 13 years, I was part of the education compliance program. And it was pulmonary, because what you have pulmonar pulmonary providers are always doubling as intensivists. And what was happening was they would use those two terms that we hate chemodynamically stable. I hate those two terms. Just like, why are you using it? And and it would be like, you know, day 15 on event, and you're like, oh my gosh, dude, you can give me something to work with here. So so the best way to identify these types of things that happen is tell the story the way you would want your peers to hear it, right? You want to be able to tell the story. It shouldn't be inferred. So if your peers were to look at it from day one to day 15 and the days that turned into critical care that became stable on and off, then you're able to actually outline the terms of life-threatening, right, versus stabilizing. They're stable, now they're life-threatening. And the best way to do that is to tell the story and don't leave out details. Be as descriptive as possible because you don't want the assumption to go the wrong way. So, yeah, I mean, in my years of doing that and working with Intensivists, they were like, Well, Maya, what do you? And they were always complaining until until one day the lead guy, and and CJ, I'm not exaggerating in this, did a Medicaid audit and he passed at 100% with Medicaid, critical care. And he was like, Wow, I don't think I would have done this without you. I was like, thanks. So, you know, when you're able to do that and teach them from day one to day 15 and the entire story of how they reacted, what you did, how you did it, what was life-sustaining, right? Deciding to put them on event, you know, deciding to do whatever it was needed in order to stabilize the patient from imminent death from happening, then that becomes the difference in good documentation and bad documentation. 

Yeah. And you know, one thing that I often see with providers who have a very, very basic or not, almost no understanding of billing for critical care. One of the biggest misconceptions is oh, the patient was in a critical care unit or an intensive care unit. Just because they're in that place doesn't automatically mean you can build critical care. It's a good starting point, but it doesn't automatically. And they don't, that's not required for them to be in that place. And I'm gonna include in the show notes a link to um some OIG audits. A couple of years ago, they had put on their work plan um physician billing for critical care. And then they actually got some audits of some provider practices that they probably identified through data analytics. And if you read those reports, you get some good insight into the point I'm trying to make is some of the findings that OIG had was look, this patient, you wrote kind of what you were saying earlier, patients hemodynamically stable, no complaints, looking good, we'll discharge later today, right? It's like at some point the patient either dies or gets better. And if they're getting better and you're going to be discharging them, and your note reads as if they're doing great, um, then just because they're doing great in a critical care unit doesn't mean it's critical care. 

So absolutely. Yeah. I mean, and a lot of things, um, especially there's a huge difference, and I think we need to talk about this too, is when they're on ICU and they're on a ventilator, there's a such thing as ventilator management versus subsequent care, right? Versus uh critical care. So if you're teaching your providers that they're on a vent and you're documenting the vent days and it's day 15, right? And try to build. Um I'm sorry, thanks for playing. We have lovely partying gifts, but this does not qualify for critical care. You may get ventilation uh management or you're gonna get a subsequent visit, but you're not gonna get critical care. So right. 

It's such a good point because a lot of patients they still might be critically ill or injured, and you might still be giving them a critical uh you might be providing a service that prevents them from deteriorating. But if it only took you five minutes, you're not gonna meet the time limit for critical care. So, no, doctor, I'm not saying this patient isn't sick. No, I'm not saying that your work wasn't life-saving. I'm saying all of that doesn't meet the time threshold. And so there are other services you can bill. And so it it you kind of already said this earlier. It's it's just, you know, approaching them and telling them then what they can bill. And oh, well, when can I build critical care? Well, when you meet this, this, and the time. Then you can start thinking about it. 

Exactly. I mean, and and you know, uh Christine Hall, uh, we both know um she always talks about what's happening today. What's happening today with the patient? So if yesterday is not what's happening today, then your note should reflect what's happening today for you to get the engaged work directly related to the individual's care, the outcome of that critical uh injured patient, and what you did in order to substantiate the life of that patient who was at at one point imminent death and contingency. So you you have to think about all of that and how CMS would view it um if someone were to audit it. So yeah. 

And you know, I used to be the director of billing compliance at a very well-known and respected cancer center. Um, and so of course, all the docs had patients who were very, very sick. They had life-threatening cancer, but they weren't gonna die today from it. Right. So that doesn't mean today's visit and every visit is a level five because they have stage four pancreatic cancer. Some patients get treated and they actually have a little bit of improvement. Everyone knows that they're still gonna die within six months, but today they're probably not gonna die. So it it that that kind of reiterates the point that you were making. And so um yeah, go ahead. 

No, I was just gonna say, but I think one thing that we also need to examine is that critical care is not limited to what's happening in the hospital. Critical care can happen anywhere. So let's say that patient is suffering and having signs of deteriorating, they're at the doctor's office, they got to go to transport to the hospital. That provider has to be in line. He can't ride in an ambulance with them, but he can direct the care and meet them at the hospital to manage that patient. So this kind of goes back to what we were talking about and kind of further explains our point that it's not limited, it's where the provider is providing the care and the nature of the presenting problem that is imminent in death. So I wanted to make sure. 

Yeah, it's such a good point. And you know, I think what I've noticed over 25 years in healthcare is there's more and more urgent care facilities popping up that are hospital out. I'm sorry, that they are physician, they're basic basically place of service 11. So they're physician practices, they're outpatient clinics, but they cater to urgent uh care. And some patients go there instead of when they should have gone to the ER. And so I anticipate that, you know, just the sheer numbers as kind of care moves a little bit more in that direction. And a lot of patients are reluctant to go to the emergency room because their copay is $150 instead of $65 at the urgent care center. Some patients might just not know and they might be directed there. You're gonna see a little bit more about what you just said, where critical care could be given in a place outside of a hospital. 

You know, and it's and I I don't want to get involved in what the government is doing, but when you think about this OBA bill, right? And you think about the lessening of uh Medicaid eligible participants, so if they can't go to their doctor, where are they gonna go? Yeah, right. And so when you think about it from that perspective, and you think about how a lot of these emergency rooms are gonna be over inundant, over uh crowded, and the amount of critical care that's gonna be reported, you know, it's gonna if if you're gonna take one here, somebody's got to take the brunt of what's happening somewhere else. So it's just really interesting how all of this stuff is gonna come into play um as it relates to that. And and we are gonna see those numbers go up extremely high uh once this comes into play. Yeah. 

Well, Maya, we are kind of coming to our end of time. Um waste. I know. We'll have you back. Um but uh any last minute thoughts or or comments before we kind of shut down for the day? 

Um well, for the day, absolutely. First of all, CJ, it's always a pleasure. We always have so much fun, and it's it's always never enough time. It's never enough time. But but What I'd like to say is, you know, before you tell the physician no, read the guidelines and do the research. Become a viable source of the information so the physician can come to you and be dependent, not won't say dependent, but openly receptive to the things that you have to say. But when you're so quick to tell them no, or you're so regimented in your process and you don't research beyond what you know, you don't become an asset. Um, you become something less. And that's what you don't want in a physician relationship with your um providers. That's a good point. 

Great ending point. Um, and you know, as I started the podcast, if there's something that you you know and that research you've done or a payer that you know does it a different way, we'd love to hear it. We're not um, you know, we're not here to say that that we are the end all, but we've done as much research as we can. And and and unless somebody can show me something else, I think we're on pretty safe ground. So that's kind of the way I approach things, and I think you do too. 

Yeah, absolutely. I mean, great minds think alike. Yours, but your your brain is bigger than mine. So I, you know, I I always defer to CJ. Yes, but it's always a great pleasure. 

Thanks, Maya, and uh really appreciate your time. And and thanks everybody for listening to another episode. As I mentioned before, we'll include a link to Maya's book. You should check it out. Um, and if you if anyone out there knows of a guest that you'd like to hear from, or if you have a topic that you'd like to hear more about, please reach out to us. We want to make these valuable episodes. And uh until next time, everyone, take care.