99291 & 99292 CPT® Codes: A Definitive Critical Care Service Resource

This 99291 CPT® lecture reviews provides a detailed review of critical care services for the physician and other non-physician practitioners (NPP).   CPT stands for Current Procedural Terminology. This code is part of a family of critical care medical billing codes described by the numbers 99291 and 99292. This procedure code lecture for critical care services is part of a complete series of CPT® lectures written by myself. I am a board certified internal medicine physician with over ten years of clinical hospitalist experience in a community hospitalist program providing physician services for a large regional hospital system. I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and other non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex and archaic world of hospital and clinic based coding requirements.

These original lectures and accompanying resources are used by myself to stay compliant with the rules and regulations of the Centers for Medicare & Medicaid Services (CMS). All my CPT® lectures have been organized in one easy-to-find resource on Pinterest and can be accessed by clicking this link. You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these CPT® evaluation and management (E/M) procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M Services Guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.

99291 AND 99292 MEDICAL CODE DESCRIPTIONS


Documentation requirements for critical care services are different than most other E/M codes.  Critical care service codes are time based codes which are not paid based on the complex rules of the 1995 or 1997 E/M guidelines or the Marshfield Clinic audit tool for medical decision making.    These CPT® codes are paid based on documentation supporting critical care evaluation and management and  required time thresholds.  I recommend all readers obtain their own updated copy of the American Medical Association (AMA) CPT® reference book  as the definitive authority on CPT® coding.   I have provided access to Amazon through the 2015 CPT® standard edition pictured below and to the right.


The AMA defines CPT® critical care procedure codes 99291 and 99292 as follows:
99291 -  Critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes
99292 -  each additional 30 minutes
Remember, CPT® code 99292 should only be billed in conjunction with 99291 due to the time based definition of the code. How does the AMA define the critically ill or critically injured patient?
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 functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition.  
How does the Centers for Medicare & Medicaid Services (CMS) define critical care service and the critically ill patient?    These are defined on page Chapter 12 on page 65 of the Medicare Claims Processing Manual.  All further references to this manual below shall be linked through this provided link. 
Pay for services reported with CPT codes 99291 and 99292 when all the criteria for critical care and critical care services are met. Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. 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 functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.
As you can see, the definitions are the same.  The critically ill patient is defined for us as having a high probability of imminent or life threatening deterioration in their condition.  Notice, this definition does not say the patient must be near death nor that they must have organ failure.  The prevention of single or multiple organ failure certainly qualifies for critical care if they have a high probability of imminent or life threatening deterioration from a failure to intervene.  In addition, continued management of the critically ill patient to prevent further deterioration also qualifies for critical care.  That means even patients who are critical but stable due to medical rescue can be billed as critical care as long as complex decision making continues to prevent further deterioration in their condition.

Critical care CPT® codes 99291 and 99292 should not be used to bill for critical care services in children up to 24 months of age.  CPT® codes 99295 and 99296 are reserved for critical care of the neonate through 28 days of life.  CPT® codes 99293 and 99294 for reserved for critical care of  a child from 29 days through 24 months of age.  These codes will not be reviewed in this lecture.

CLINICAL EXAMPLES APPROPRIATE FOR CRITICAL CARE SERVICES


The AMA doesn't provide specific clinical scenarios for coding critical care services.  They do, however, provide general examples of vital organ system failure.  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 are all examples of critical illness.  I came up with a few clinical scenarios that I, as a hospitalist, would have no concerns about billing critical care, assuming the 30 minute time threshold for CPT® 99291 has been met and I am the physician managing the critical aspects of the patient's illness in part or in whole.
  • Being called to the bedside to evaluate opiate overdose from PCA with shallow breathing.
  • New onset seizure with fever on a floor patient with multiple other medications and medical problems. 
  • Evaluation of acute hypotension of any cause.
  • Supraventricular tachycardia requiring Adenosine intervention.
  • Admission for acute renal failure with critical hyperkalemia being managed with or with acute dialysis.
  • Admission for symptomatic hyponatremia requiring 3% NaCl.
  • Admission for pneumonia or COPD exacerbation requiring BiPAP therapy.
  • Admission for large volume gastrointestinal bleeding with tachycardia.
  • Admission for severe DKA requiring an insulin drip.
  • Admission for symptomatic hypertension with headache or chest pain on medication infusion therapy.
  • Admission for rapid atrial fibrillation on continuous Amiodarone infusion.
  • Being called to the bedside to evaluate chest pain with new ST elevation EKG changes.
  • Being called to the bedside to evaluate a patient with acute stroke signs and symptoms. 
On page 67 of the of the Medicare Claims Processing Manual linked above, CMS provides examples of patients who's medical condition may warrant critical care services:

CMS examples of patients who may qualify for critical care services


CLINICAL EXAMPLES NOT APPROPRIATE FOR CRITICAL CARE SERVICES


What are some situations when billing for critical care is not appropriate?  CMS has explained this too on pages 67 - 69 of the Medicare Claims Processing Manual linked above, they describe the following situations when billing for critical care services is not appropriate:
  • Patients admitted to a critical care unit because no other hospital beds were available;
  • Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs(e.g., drug toxicity or overdose);
  • Patients admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit.
  • A dermatologist evaluates and treats a rash on an ICU patient who is maintained on a ventilator and nitroglycerine infusion that are being managed by an intensivist. The dermatologist should not report a service for critical care.
  • Daily management of a patient on chronic ventilator therapy does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the ventilator dependence.
  • Management of dialysis or care related to dialysis for a patient receiving ESRD hemodialysis does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the dialysis dependence (refer to Chapter 8, §160.4). When a separately identifiable condition (e.g., management of seizures or pericardial tamponade related to renal failure) is being managed, it may be billed as critical care if critical care requirements are met. Modifier –25 should be appended to the critical care code when applicable in this situation.

RELATIVE VALUE UNITS (RVUs)


How much money does a CPT® 99291 or 99292 pay? That depends on what part of the country you live in and what insurance company you are billing. E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs). This complex RVU discussion has been had elsewhere on The Happy Hospitalist.  What are the RVU values for critical care service codes 99291 and 99292 in 2014?  A complete list of RVU values on common hospitalist E/M codes is provided here. The dollar conversion factor for one RVU in 2014 is 35.8228.
  • 99291 -  work RVU:  4.50;  total RVU (facility):  6.27;  total RVU (non-facility): 7.67.  In my state, this pays just under $212 for facility and $257 for non-facility sites of service. 
  • 99292 -  work RVU:  2.25;  total RVU (facility): 3.14;  total RVU (non-facility):  3.44.  In my state, this pays just over $106 for facility and $115 for non-facility sites of service.  
How often are critical care codes billed to Medicare?  Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99291 and 99292 encounters were billed and the dollar value of their services for Part B Medicare. 
  • 99291
    • Allowed services - 5,045,749
    • Allowed charges - $1,115,802,740.49
    • Payments - $883,570,446.70 
  • 99292
    • Allowed services - 434,120
    • Allowed charges - $47,655,254.17
    • Payments - $37,959,581.04

WHEN CAN CRITICAL CARE SERVICES BE BILLED?


Critical care can be billed any time the visit meets the criteria for billing critical care.  That means it can be billed as the admitting history and physical or as a hospital followup note or clinic evaluation.  There are no exclusions about when or where this service code group can be used. 

WHERE CAN CRITICAL CARE SERVICES BE BILLED?


Critical care service codes 99291 and 99292 can be billed at any site of service.  That means they can be billed in the ER.  They can be billed on a general care floor or other non-ICU monitored unit.  They can be billed in the office setting during routine clinic visits.  They can even be billed in a nursing home.  Appropriate used of critical care codes is based on the patient's condition and the intensity of the service provided by the physician or other non-physician practitioner, not on where the face-to-face encounter takes place.  The Medicare Claims Processing Manual explains this on page 66:
Providing medical care to a critically ill, injured, or post - operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements. Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care.
With that said, being in the ICU does not automatically qualify a patient as appropriate for the use of critical care codes.  The Medicare Claims Processing Manual specifically explains this scenario on page 66:
Critical care services must be medically necessary and reasonable. Services provided that do not meet critical care services or services provided for a patient who is not critically ill or injured in accordance with the above definitions and criteria but who happens to be in a critical care, intensive care, or other specialized care unit should be reported using another appropriate E/M code (e.g., subsequent hospital care, CPT codes 99231 - 99233).

DOCUMENTATION REQUIREMENTS


Documentation requirements for critical care services do not include all the complex E/M rules necessary for many other hospital or clinic encounters.  There are no rules for obtaining bullet points for history or physical.  There are no requirements to add up points in the complex E/M rules I have detailed below on my bedside pocket reference card.  However, the documentation must support care for a patient who meets the definition of a critical ill or injured patient and an intensity of service consistent with the requirements of these service codes.  Documentation must also support time thresholds necessary to bill these critical care codes.

TIME BASED BILLING CONSIDERATIONS

 

     TIME THRESHOLD TABLE


How do I know when to bill 99291 and or 99292 during a critical care evaluation?  The following table is provided on page 72 of the Medicare Claims Processing Manual detailing how many 99292 codes should be billed based on the total critical care time spent on any given calendar date. If less than 30 minutes is spent, an alternative E/M code should be chosen that is supported by the face-to-face documentation (such as a 99233 or a 99223). 

Critical Care 99291 and 99292 time threshold table


     IS THERE A LIMIT TO THE NUMBER OF 99292'S THAT CAN BE BILLED?


No.  There is no limit.

      DOES CRITICAL CARE TIME HAVE TO BE CONTINUOUS?


Critical care time does not have to be continuous.  Non-continuous time should be aggregated and the total time should be reported and coded based on the above time thresholds for 99291 and 99292.  Billing a 99291 is a prerequisite to billing 99292.  The Medicare Claims Processing Manual discusses this issue on page 68:
The CPT critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non - continuous time for medically necessary critical care services may be aggregated.

     DOES CRITICAL CARE TIME HAVE TO INCLUDE A START AND STOP TIME OR JUST TOTAL TIME?


I could find no reference on CMS documents that a start time and a stop time is necessary to bill for critical care services.  On page 68 of the Medicare Claims Processing Manual is the following statement.
Critical care is a time - based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided. 

Documenting start and stop times for critical care may help prevent accusations of fraud when clinicians need to document procedural time as independent of  critical care time.


CRITICAL CARE SERVICE REQUIREMENT FOR BEING IMMEDIATELY AVAILABLE.



In order to bill for critical care services, the clinician must be immediately available to the patient (immediate bedside or elsewhere on the floor or unit).  Time spent off the unit making phone calls or reviewing data cannot count toward the aggregate critical care time spent.  The time spent on the unit (such as reviewing data or discussing case with other health care professionals) should be fully devoted to the patient and no other services for other patients should be performed during this qualifying time.  Qualifying time includes work directly related to the individual patient's care whether that time is at the immediate bedside or elsewhere on the floor or unit.  Page 68 of the Medicare Claims Processing Manual says:
For example, time spent reviewing laboratory test results or discussing the critically ill patient's care with other medical staff in the unit or at the nursing station on the floor may be reported as critical care, even when it does not occur at the bedside, if this time represents the physician’s full attention to the management of the critically ill/injured patient. For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

CAN CRITICAL CARE BE BILLED MORE THAN ONE DAY IN A ROW?


Yes.  Critical care can be billed on multiple days.  


WHAT WORK CAN BE INCLUDED IN CRITICAL CARE TIME ON THE FLOOR OR UNIT?


Time that can be reported as critical care includes all work directly related to the individual patient's care including reviewing test results or imaging studies, discussing care with other health care professionals, documentation in the medical record (H&P or progress notes) and time spent with family members obtaining information and formulating a plan when the patient is unable to participate in the evaluation process.   The time spent in the work must be fully devoted to the patient's care.  I have provided a more detailed discussion on billing for family conferences in the ICU


WHAT WORK SHOULD NOT BE INCLUDED IN CRITICAL CARE TIME ON THE FLOOR OR UNIT?



Some procedures are billed separately from critical care services.  Time spent on those services cannot be included for critical care services and the separate time should be documented in the patient's chart.  The Medicare Claims Processing Manual specifically describes this issue on page 69:
The physician's progress note(s) in the medical record should document that time involved in the performance of separately billable procedures was not counted toward critical care time.
In addition, time spent in activities that do not directly contribute to the treatment of the patient may not be reported as critical care.  For example, time spent in meetings and telephone discussions about other patients should not be included.  In addition, do not include routine updates to family members or other surrogate decision makers as this time is considered part of  pre and post service work for CPT® codes 99291 and 99292.    Review of literature and teaching sessions with residents or other healthcare providers should also not be counted toward critical care time according to page 70 of the  Medicare Claims Processing Manual.


WHAT WORK OFF THE UNIT OR FLOOR CAN BE BILLED AS CRITICAL CARE?



Billing for critical care services requires the clinician to be immediately available at the bedside or on the floor or unit.  Time spent on activities not on the floor, even if related to the patient's care, such as telephone orders, reviewing data or discussion with family members or other physicians while off the unit should not be billed as critical care services.

CAN CRITICAL CARE AND OTHER E/M SERVICES BE BILLED ON THE SAME PATIENT ON THE SAME DATE?


Do not report emergency department visit services and critical care services in the same visit (page 72 of the Medicare Claims Processing Manual).  Under certain circumstances, critical care and other E/M charges can be billed on the same day when the critical care services are provided after an initial non-critical E/M encounter.  I have discussed this circumstance in greater detail here.

What about the scenario when critical care services are provided and then the patient is discharged, often to another tertiary hospital.  Can critical care codes 99292 and or 99292 be billed on the same calendar date as discharge services 99238 and or 99239?  I have heard different opinions on the matter.  Ultimately, the clinician can submit payment for both and they may or may not get paid.  My instinct is that other E/M services should not be reported after critical services have been provided on any given calendar date.  I would personally submit additional 99292 add-on codes for the work provided in discharge, assuming the work being provided still qualifies for critical care service.   

In my opinion, this work should be paid as critical care as long as the physician maintains presence on the floor or unit and is immediately available.  The medication reconciliation process and discharge summary all involve critical aspects for the transfer of information to the accepting team and should be paid, just as these elements would be covered on the admission process for critical care services.

BILLING FOR CRITICAL CARE SERVICES AND CPR (CPT® CODE 92950).


I have provided a detailed discussion on how to bill for critical care services in the setting of cardiopulmonary resuscitation.  That discussion can be found here.

CAN CRITICAL CARE SERVICES BE BILLED AFTER THE PATIENT HAS DIED?

 

Of course not.   A dead patient is not critically ill.  They are dead.   


CAN TWO PHYSICIANS BILL FOR CRITICAL CARE ON THE SAME PATIENT ON THE SAME DATE?


Yes.  The Medicare Claims Processing Manual specifically says so on page 68:
More than one physician can provide critical care at another time and be paid if the service meets critical care, is medically necessary and is not duplicative care. Concurrent care by more than one physician (generally representing different physician specialties) is payable if these requirements are met (refer to the Medicare Benefit Policy Manual, Pub. 100 - 02, Chapter 15 , §30 for concurrent care policy discussion). 
Here is the link to the Chapter 15 (page 13) of the Medicare Benefit Policy Manual that provides a definition and description of concurrent care.   Stated another way, MLN Matters document 5993 (page 8) indicates critical care service should be paid to more than one physician on the same date regardless of whether the physicians are in the same group practice or different group practices (usually of different physician specialties)  if the concurrent care meets critical care requirements, are medically necessary and are not duplicative.  Make sure the review the definition of concurrent care linked above  for more detailed about billing by physicians of the same specialty (and different group practice) on the same day.  These services may be paid, under certain circumstances.

Further more, pages 72 and 73 of the Medicare Claims Processing Manual states the following:
Medically necessary critical care services provided on the same calendar date to the same patient by physicians representing different medical specialties that are not duplicative services are payable. The medical specialists may be from the same group practice or from different group practices. Critically ill or critically injured patients may require the care of more than one physician medical specialty. Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time. Medical record documentation must support the medical necessity of critical care services provided by each physician (or qualified NPP). Each physician must accurately report the service(s) he/she provided to the patient in accordance with any applicable global surgery rules or concurrent care rules. (Refer to Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, §40, and the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, §30.)

CAN TWO PHYSICIANS BILL FOR CRITICAL CARE ON THE SAME PATIENT AT THE SAME TIME?


Page 72 of the Medicare Claims Processing Manual clearly states that two physicians cannot provide critical care services to the same patient at the same time.
Critically ill or critically injured patients may require the care of more than one physician medical specialty. Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time.
In my experience, many physician evaluations occur at the same time, especially when critically ill patients require a multidisciplinary approach with constant communication with physician colleagues.  I believe this rule is a tragedy.  I am uncertain how often claims are denied when two different physicians of different specialties provide critical care services at the same time.  Medically, this rule is obstructive to high quality care.  To decline payment for medically necessary services because the patient was receiving expert advice from more than one physician is not good public policy.  For example, critically ill patients who require emergent dialysis or intubation often have multiple physicians providing critical care evaluations at the same time.

In my opinion, there is no medical justification to deny payment for all but one expert opinion during a given period in time in these cases. This discourages the team approach to care.  In addition a patient requiring urgent evaluation often needs rapid intervention by multiple different physicians.  For example a patient with acute respiratory failure requiring pulmonary physician expertise may also require the services of a cardiologist if that patient is also having an acute ST elevation MI.   Grave patient harm can and will occur if CMS denies payment for both physician services simply because they occurred at the same instance in time.  And denial of payment is simply inappropriate for circumstances like this.

CAN A NURSE PRACTITIONER OR PHYSICIAN ASSISTANT BILL FOR CRITICAL CARE SERVICES?


Yes.  Nurse practitioners and physician assistants can bill for critical care services under their own National Provider Identifier (NPI).  The service must be under their scope of practice and licensure requirements for the State in which the services are being provided.  This is described on page 68 of the Medicare Claims Processing Manual. 

CAN A PHYSICIAN BILL FOR CRITICAL CARE SERVICES USING SPLIT/SHARED TIME WITH A NURSE PRACTITIONER OR PHYSICIAN ASSISTANT?


No.  Split/shared billing is not allowed for critical care services.  The time spent must be indicative of a single physician or non-physician practitioner.  This is described on page 69 of the Medicare Claims Processing Manual.

CAN RESIDENT PHYSICIAN TIME SPENT ALONE OR TEACHING BE USED TO BILL FOR CRITICAL CARE SERVICE?


No.  Time spent by residents without physician presence cannot be used for critical care service time threshold requirements.    While the physician may refer to the residents documentation, time spent without physician presence cannot be used.  In addition, time spent teaching and instructing team members should not be used to aggregate total critical care time.  Pages 76 and 77 of the Medicare Claims Processing Manual address these issues:
In order for the teaching physician to bill for critical care services the teaching physician must meet the requirements for critical care described in the preceding sections. For CPT codes determined on the basis of time, such as critical care, the teaching physician must be present for the entire period of time for which the claim is submitted. For example, payment will be made for 35 minutes of critical care services only if the teaching physician is present for the full 35 minutes. 
Time spent teaching may not be counted towards critical care time. Time spent by the resident, in the absence of the teaching physician, cannot be billed by the teaching physician as critical care or other time-based services. Only time spent by the resident and teaching physician together with the patient or the teaching physician alone with the patient can be counted toward critical care time.

Refer to page 77 of the Medicare Claims Processing Manual for appropriate and inappropriate examples of teaching documentation for use with critical care services.

CAN TWO PHYSICIANS OR NON-PHYSICIAN PRACTITIONERS IN THE SAME SPECIALTY AND GROUP PRACTICE COMBINE THEIR TIME TO BILL CPT® 99291?


No.  CPT® 99291 time thresholds must be met by only one person.  Times cannot be combined to meet the 30 minute threshold required to bill this initial critical care service code.  This requirement is clearly stated on page 73 of the Medicare Claims Processing Manual.

CAN TWO PHYSICIANS OR NON-PHYSICIAN PRACTITIONERS IN THE SAME SPECIALTY AND GROUP PRACTICE COMBINE THEIR TIME TO BILL CPT ®99292


Yes.  CPT® 99292 can be billed using the aggregated times of physicians and non-physician practitioners from the same specialty and group practice.  This scenario is further described in greater detail on page 72 of the Medicare Claims Processing Manual.  The service should be billed using the NPI number of the physician or non-physician practitioner.  In addition, make sure to review the next question in detail for important information on how to code for critical care services across different physician shifts on the same calendar date.

CAN TWO PHYSICIANS OR NON-PHYSICIAN PRACTITIONERS IN THE SAME SPECIALTY AND GROUP PRACTICE BOTH REPORT CPT® 99291 ON THE SAME PATIENT ON THE SAME CALENDAR DATE? 


No.  CPT 99291 can only be billed once per day by physicians in the same specialty and group practice. As a rule, Medicare payment policy states that physicians in the same group practice who are in the same specialty must bill as if each were the single physician.  Here is the link (on page 50) to Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.5 that details this billing requirement for same specialty and same group.

Instead of two physicians of the same specialty and same group practice billing for CPT® 99291 on the same calendar date, CPT® 99292 should be used instead once aggregate time thresholds have been met.   This is a very common scenario in hospitalist shift based care.  If one partner admits the patient on the night shift using critical care CPT® code 99291 and the day hospitalist provides additional critical care services later on the same calendar date of at least 30 minutes, the second hospitalist cannot also bill CPT ® 99291.  They should use CPT® code 99292 if the 74 minute threshold has been achieved when combining their time and their admitting hospitalist's time.

In the past this has caused denials of payment as CMS computers were unable to process add on code 99292 when performed by a physician or NPP with a different NPI number than was provided for the 99291 evaluation.  I wrote about these problems getting paid for 99292 several years ago.

This problem was fixed in January, 2013 and is detailed in Transmittal 2636 of the CMS Manual (Thanks to Today's Hospitalist Facebook Page for the heads up) as part of a National Correct Coding Initiative (NCCI) for add-on codes.

HOW TO HANDLE CRITICAL CARE CODING WHEN TWO PHYSICIANS OF THE SAME GROUP AND EXACT SAME SPECIALTY PROVIDE CRITICAL CARE SERVICES ON THE SAME DATE.


See the detailed description in the four sections just above this.  Make sure to understand these important details to remain compliant with CMS and to get paid for critical care services provided.

 

WHAT PROCEDURES ARE BUNDLED INTO CRITICAL CARE SERVICES?

 

2008 Medicare resource document MLN Matters Number 5993 provides the most updated list of procedures that are bundled into critical care services and should not be billed separately by the physician when performed during the critical care period.  They are:
  • the interpretation of cardiac output measurements (CPT 93561, 93562)
  • chest x-rays, professional component (CPT 71010, 71015, 71020)
  • blood draw for specimen (CPT 36415)
  • blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data (CPT 99090))
  • gastric intubation (CPT 43752, 91105)
  • pulse oximetry (CPT 94760, 94761, 94762)
  • temporary transcutaneous pacing (CPT 92953)
  • ventilator management (CPT 94002 – 94004, 94660, 94662)
  • vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600)
Procedural services not listed above should be billed separately and independently of critical care services.  Note, the common CPT® code used for placement of central lines (CPT®36556) is not listed here and should be billed separately. Make sure to document the time spent in these additional billable procedures was independent and separate of critical care time.  Page 69 of the Medicare Claims Processing Manual says this:
Time involved performing procedures that are not bundled into critical care (i.e., billed and paid separately) may not be included and counted toward critical care time. The physician's progress note(s) in the medical record should document that time involved in the performance of separately billable procedures was not counted toward critical care time.


CAN CRITICAL CARE SERVICES BE BILLED DURING GLOBAL SURGERY PERIODS?


Critical care can be billed under certain circumstances.  As I do not bill based on global surgery rules, I refer readers to the Medicare Claims Processing Manual on pages 75 and 76 for details.

HOW IS CRITICAL CARE TIME AGGREGATED WHEN THE VISIT CROSSES THE MIDNIGHT HOUR?


For critical care services that cross the midnight hour and meet the 30 minute threshold, payment  for CPT® 99291 should be submitted on the calendar date when the face-to-face encounter began.   If evaluation becomes non-continuous after the midnight hour and subsequent critical care service is provided, an additional CPT ®99291 should be considered if the 30 minute threshold is again achieved.  For example, if you are a hospitalist and you take care of a direct admit  by providing continuous critical care service from January 1st 11:45 pm to January 2nd at 12:20 am and provide no more critical care on January 2nd, you should submit payment for CPT® 99291 on January 1st.  However, if you leave the ICU and go take care of another patient from 12:20 am to 12:30 am and then get called back to provide critical care services from 12:30 am on January 2nd to 1:05 am on January 2nd, you should also submit an additional payment for CPT ® 99291 on January 2nd.




LINK TO HOSPITALIST POCKET CODING CARD POST


EM Pocket Reference Cards Using Marshfield Clinic Point Audit



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  1. Wow. A link and a sidebar citation! I'm honored.

    Cheers,

    SF

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