Problems Getting Paid For Critical Care CPT® Code 99292 FIXED!

A reader asked me a question that has been on my mind for many years.   It involves critical care CPT® medical coding services.  You see,  critical care service is billed based on time.  The first 30-74 minutes is billed a CPT® code 99291  (reference the AMA's CPT 2014 Standard Edition as the definitive CPT authority).  It is available from the photo link below and to the right to Amazon.   A  Every 30 minute interval there after, in the same calendar day is billed an additional 99292.  This is an add on code.  You cannot bill a 99292 without first having billed a 99291 on the same calendar day.
I have a question.  I have had a really hard time with correctly getting this scenario paid and billed correctly pertaining to critical care in a hospitalist setting/group. If physician A does 45 minuted critical care (99291) and Physician B does an additional 30  minutes (99292) both being fully credential (meaning they are not locums) in the same day, how do you bill this? You can not bill the 99292 separately on an invoice because it's an add on code. I was told that I could give the charge to physician A who provided the 99291 (because they get paid salary) but my boss says that's wrong and that each service needs to be billed by the rendering provider. We are losing a lot of money writing off the denied charges for the 99292 being provided by a different doctor but same group. Thank you in advance for your input. It's greatly appreciated.
The problem arises when two members of the same group (for example a hospitalist group) see the same patient on the same day.  How do two members of the same group bill critical care?  Medicare says that because the two members are treated as the same, billing a 99291 by one member and a 99292 by another member should be OK.

However, I have confirmed with my coding company that these rules cannot be applied as written because of the way Medicare's computerized payment system is structured.   If you submit a code for 99291 by one physician,  then submit a 99292 by a second physician, the Medicare computers will reject the 99292 because it is being submitted as a stand alone code by physician number two and the Medicare computers will only accept it as an add on code.  Therefor, even though the Medicare rules say it should be OK for two physicians of the same specialty and group to bill out separate 99291 and 99292 charges, the Medicare computers will reject it based on their inability to connect the dots.

As my coding people told me. Even thought Medicare rules clearly state that physician number two should be able to bill out a 99292 as a stand alone charge, the computer systems at Medicare will reject it because it is only allowed as an add on charge. As my billing people state :
The 99292 is an add on code and it can’t be billed on a claim by itself. Medicare’s edit systems are set up to reject add on codes that do not show up on the HCFA with the primary code. You can’t put two different providers on one HCFA so there is no other way to get paid for the time spent by a group practice unless you add up the times and bill under the provider who provided the majority of the critical care services for that calendar day. I have been to various conferences and each time they have said that the time would need to be added up and billed under the primary treating provider in that group for that day.
UPDATE 2013:   This problem has been solved in 2013.  Transmittal 2636 of the CMS Manual System has provided an exception to the add-on code rules as part of a National Correct Coding Initiative (NCCI).  You can read about this change at the link provided for Transmittal 2636.   Physicians in the same specialty and group practice can and should bill stand alone 99292 codes even if their partner submitted payment for 99291.  They can add up time from their partner to meet threshold times for 99292 as well. I have provided the most complete resource center for all issues related to billing for critical care services that I encourage all readers to review.

You can see much more in my free lectures on coding for hospitalists and a wealth of other important information in my resource center.


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35 Outbursts:

  1. I'm missing the point. For physicians in the same group, you can add up the time of all of you, and if you are paid by billing, split the payment from Medicare among yourselves based on time spent by each.

    For physicians from multiple groups, each group can submit a separate bill, correct?

    Under what circumstances would the physician earning a living based on billing not get paid?

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  2. Physicians within the same group rarely split the billing. Your incentives are generally based on your personal billing.

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  3. Anonymous, that is not the complaint that Dr. Happy is making. But in answer to your response, let me just say that the solution to the problem lies within your group. If you understand the need to add up all of the physicians' times to create a single bill, under a single physician's name, then you KNOW that's what's going on. You should be able to change your "incentives" to reflect that. If not, you are as bad at bureaucracy as Medicare is.

    And just for the record, Medicare is wrong, but I'm a pragmatist. There is a way around this particular bit of Medicare stupidity; why not use it?

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  4. Wow, you really have no idea what you're talking about, do you? If my partner has 200 encounters in a month and I have 600 and we share billing, I'm not going to be receiving my fair share of bonus/incentive based on productivity. We're not going to change that because one of Medicare's rules is asinine. The model actual makes perfect sense. You work more and are more productive, you make more.

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  5. I had this happen with trying to see two DO's in one day. One doc was a follow-up to Botox shots in my cervical and thoracic spine a month prior and the other is my pain management doctor. Both are in the same practice.

    The receptionist called me before my appointment and told me that I needed to split the appointments to see one doc one week and the other doc the next week because one or the other doc could not/would not get paid by my insurance company (Anthem).

    In their practice they do not bill one doctor's time under another doctor's time, but bill separately. So I saw one doc one week and the other doc the next week.

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  6. Wow, you really have no idea what you're talking about, do you?

    Perhaps not.

    I'm just trying to understand why you can't solve the problem other than trying to make the U.S. federal government change the way it does things. Is that really easier than modifying/adding to/replacing your billing process so that you can track how much each physician did, regardless of whose name was submitted on the bill to Medicare? Are the incentives paid by Medicare or what? I'm clearly missing a piece of information.

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  7. Are they requesting supporting documentation for the 99292? Critical Care codes have a high CERT rate. Is your MAC doing a review of critical care?

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  8. The FI for my neighborhood says: "Physicians in the same group practice who have the same specialty may not each report CPT initial critical care code 99291 for critical care services to the same patient on the same calendar date. Medicare payment policy states that physicians in the same group practice who are in the same
    specialty must bill and be paid as though each were the single physician. (Refer to the Medicare
    Claims Processing Manual, Pub. 100-04, Chapter 12 and §30.6)"

    If the 99292 guy who follows you has a different specialty and provides services unique to that specialty, he could also bill 99291...

    Sheesh - don't the people at CMS have anything better to do?

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  9. Hey, You bring up a good point. I was never aware of the difficultites getting paid for an encounter that Medicare's own rules state should be payable. The fact that their system disallows payment for an encounter that it should allow is irrational, but not unexpected.

    As far as bundling a payment for the 99292 add on code within a group practice so that at least the group gets paid, you are correct, that is something that groups could in all likelihood evaluate. Perhaps it will make a difference. Perhaps it wont.

    This bundling does little in the eat what you kill production model. For docs who are paid on production, the incentive to go see a patient and allow their partner to collect the fruits of their labor is, in all likelihood, not gonna happen.

    More likely, if the patient gets sicker a call in of the specialists will occur. Docs who will get paid to evaluate the patient.

    That's human nature.

    Do more make more. Do more make less doesn't cut it in an eat what you kill mentality.

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  10. anon. I'm not sure what you are trying to say. If two physicians are of different specialties, even if they are in the same group, they can both bill a 99291 on the same calendar day. That isn't being argued. It's the issue of hand offs to a doc of the same specialty in the same group. They should be able to bill an add on 99292 code according to Medicare rules. But the Medicare computers reject the claim because the claim is submitted with out the accompanying 99291 from the other physician.

    That's my beef. Medicare rejects their own rules that they establish, and then come back and accuse docs of fraud when they don't follow the same rules.

    It is irrational at best,

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  11. I believe a MAC is a Medicare Administrative Contractor.

    Medicare's own rules specify that the right way to bill it is to add them all up and bill under a single physician.

    I again ask the question which no-one has answered, why can't doctors who have grouped together just agree among themselves that this kind of billing will be done under one of their names, but the split of payment/incentives/whatever will be agreed upon by the doctors as if the billing had been submitted separately?

    As far as I can see, you guys are arguing that you can't keep books properly with a single account, you must have a separate account for each item. Imagine if I went to my bank and insisted that they give me a different savings account for each stock that pays me a dividend by direct deposit. I keep track of that with my bookkeeping software. It matters not that all of the funds go into a single account. I do the same with paying utilities. I do not need a separate checking accounts to know that part of my money goes to electric, some to gas, some to phone, etc.

    Again, what am I missing here?

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  12. Hey you. Again, what you posted was how Medicare will pay. That is the only way they will pay. Even though their guidelines state that two physicians of the same specialty can bill a 99291 and 99292 independently. You can bill it. Medicare just won't pay it.

    The problem is, the computers won't recognize it. That's why Medicare says to bill it under one doc. These are two separate and identifiable encounters. They should be processed individually by the correct doc. The Medicare computers just won't allow it.

    Also, I think what you are saying is that groups should have a second set of books that run parallel to the real books. The real books would show Doc A getting credit for accounts receivable for the fifty 99292 in 2008 billings from Doc B.

    A second set of books that run parallel to the real books would show Doc B as the rightful Doc for account receivables for those 50 99292 billings for 2008.

    Now imagine you have a second set of books for all 20 docs in the group. Each trying to verify the accuracy of their accounts receivable from the real books and cross referencing it with the second set of books that are running parallel.

    So which set of books does the IRS use?

    Which set of books will the Medicare Audit recovery team use?

    Is running a second set of books even consistent with good accounting principles.

    Hey you. I think what you are saying is that the groups should have a second set of books.

    I would argue that is a horrible, horrible way to run a business.

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  13. Are your records being requested for review? Are you appealing the decision?

    I am more inclined to think it would be better for changed to take place in the CPT and change this code from an "add on" - which will not get paid without a primary code billed - to a stand alone code for additional providers.

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  14. So again, Hey You is proposing that we completely overhaul our billing system to account for an error that Medicare perpetuates. How about just getting them to fix the problem like Happy suggests?

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  15. You can bill it. Medicare just won't pay it.

    The sooner you accept this true statement, the sooner you will find an answer to this problem.


    Hey you. I think what you are saying is that the groups should have a second set of books.

    Absolutely not. That would be illegal, and it would get you into very bad trouble if the auditors found out.

    I am suggesting that your current bookkeeping practices are insufficient to accommodate all of Medicare's weird and stupid rules. You need to change them so that you can do what you need and still get paid. I wouldn't be surprised if other doctors have this same problem, and I wouldn't be surprised if there isn't already accounting software out there that handles this particular problem so that Medicare is happy and the doctors get their appropriate credit and payments.


    So again, Hey You is proposing that we completely overhaul our billing system to account for an error that Medicare perpetuates. How about just getting them to fix the problem like Happy suggests?

    Anonymous, you are taking your anger out on me. Why? Because you think I don't understand, because you think I am in favor of Medicare's dumb processes, because you don't like it that I am forcing you to face reality?

    So let me ask you, which is easier for you to do, getting the federal government to change the way it does something, or adapting your own actions so that you can live with the rules of Medicare and still get what you want?

    People who constantly demand that everyone else change to suit them are at a huge disadvantage in life. You're going to always be unhappy. Rather, understand that you can't change others who don't want to change and your best bet is to wield the power you actually have. Then you will find peace with others' behavior that you do not like.

    I have proposed a solution. It matters not to me whether you adopt it or not. There may, in fact, be superior solutions. I simply suggest that waging war against the Medicare bureaucracy is likely to result in zero success and an abundant frustration.

    Dr. Happy, if I might ask, can you site a source for your claim that "Medicare rules clearly state that physician #2 should be able to bill out a 99292 as a stand alone charge"? I have been unable to find that.

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  16. **I'm an MT primarily**

    An interesting thing I have noticed while transcribing for a large (I presume) teaching hospital associated with the VA is a little notation at the end of each discharge report.

    Now, mind you, many discharges are being dictated by residents. We have a computer program in place whereby we note who the attending is so we can document that for signature line purposes.

    I have also observed that the attending admitting physician on record is NOT the same as the attending of record for discharge.

    Even still, at the end of these reports, there is a statement that goes something like this, "Note: 45 minutes were spent on preparing discharge documents, counseling, medication lists and instructions."

    Stay with me here. As an MT, I am paid on production, strictly production. My pay is X CPL (cents per line) for X char (characters). We also receive CPL incentives on top of our base CPL for weekend work, night shift work, etc. They also calculate in overtime pay. We ARE employees of this group, not ICs.

    This is billed under our "group" of MTs. All of our individual activity is managed via an internet website where we can see what we produced/billed.

    So, I'm with HeyYou. Why can't your group come up with a standardized billing function for Medicare and yet recognize your individual efforts?

    **and you thought it was complicated on YOUR end of the healthcare mosaiac. We, as ancillary service providers, feel it too.**

    P.S. If I had my druthers, we would charge by the dictated minute instead of this crazy character line method. This puts the onus back on the dictator to be clear, concise, and not the eternal page-flipper (although I would prefer that for MY income based on that model).

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  17. Hey You. My coding people sent me the following, word for word in Medicare guideline. I don't know where it's sited. Only that my coding people have it in their reference material:


    However, if a physician or qualified NPP within a group provides “staff coverage” or “follow-up” for another group physician who provided the first hour of critical care services on that same calendar date but has left the care to a second physician the second group physician or qualified NPP should report the CPT critical care add-on code 99292 or another appropriate E/M code.

    Clinical Examples of Critical Care Services

    1. Drs. Smith and Jones, pulmonary specialists, share a group practice. On Tuesday Dr. Smith provides critical care services to Mrs. Benson who is comatose and has been in the intensive care unit for 4 days following a motor vehicle accident. She has multiple organ dysfunction including cerebral hematoma, flail chest and pulmonary contusion. Later on the same calendar date Dr. Jones covers for Dr. Smith and provides critical care services. Medically necessary critical care services provided at the different time periods may be reported by both Drs. Smith and Jones. Dr. Smith would report CPT code 99291 for the initial visit and Dr. Jones, as part of the same group practice would report CPT code 99292 on the same calendar date if the appropriate time requirements are met.

    That's the basis of my discussion.

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  18. pink. There are systems in place to track production. Imagine if judy, a coworker transcribef 10 lines of an H&P imagine the dictation is only ten lines because the resident accidently disconnected the phone

    Now imagine if the resident called back in to finish the dictation. Only this time you are assigned the dictation only this time it is 500 lines of inaudible intern rambling that takes 30 minutes to transcribe

    Now imagine Judy gets the credit for any production incentive you have in place because that's just the way it works. Now do you develop a second set of books to regive yourself back credit worked by another MT? You would have to. I'm saying you shouldn't have to.

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  19. Okay, I see where you are coming from; however, each "encounter" we have with a document comes with its own company-provided and tracked identification document number and separate MT identification number.

    Each one tracks the document and whose hands touched it. Therefore, this eliminates the confusion on when each document is "handed off," so to speak, to another MT provider within said company.

    No it SHOULDN'T be this way, but when you have production incentives tied to employee status, SOMETHING has to be in place to track it accurately. Otherwise, there is no point in even having a production incentive. If it can be done for an MT group/company, it can be done for a hospitalist group as well.

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  20. And now that I am thinking about it, why not talk to medical records? I would ASSume that somehow and someway documentation can be provided to allow your group to get paid for the encounters you described and track production. Of course, I'm sure that will come at some kind of cost to your group.

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  21. Happy--here is your link to the information you provided..

    http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5993.pdf

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  22. Well..that was very blonde of me, LOL Sorry All for the faulty triple posting.

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  23. Thank You Neon.

    Pink, medical records has nothing to do with our billing company.

    Nothing at all.

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  24. Dr. Happy, I have found a document that may be similar to what your coding people work from. I don't know that it is the one they are using, but I'm going to assume it contains the same stuff relative to this issue.

    The whole controversy appears to revolve around a very poorly worded example. The part you quoted is at the bottom of page 7 of the document I linked. If you back up just a little bit, you'll find some context for that, which reads, in part, Medicare payment policy states that physicians in the same group practice who are in the same specialty must bill and be paid as though each were the single physician. We've seen that before, but the point here is that it is part of the context of the example you cite.

    Where I think it gets confusing is where the example says, "Dr. Smith would report CPT code 99291 for the initial visit and Dr. Jones, as part of the same group practice would report CPT code 99292 on the same calendar date."

    Now what does "report" a CPT code mean, exactly? You are assuming that it means "bill." In the fuller context, higher up on page 7, it seems to make it clear that it CAN'T mean billing.

    So I would assume that it means "report to the billing department" with the understanding that the billing department will then send a bill to Medicare under a single physician's name.

    It could be that the example flat out contradicts the stated policy. In that case, I would go with the policy statement and ignore the example, especially when all of the links back to actual governmental sites agree with the policy statement, not the example.

    It could be that whoever wrote this document copied the policy down from the Medicare documents, but then didn't understand it when he/she came up with an example.

    Personally, I think the writer of the example intended to illustrate that only 1 doctor in the same-speciality practice can submit a 99291, not to illustrate that both doctors can submit bills to medicare. He screwed the example up.

    In any event, I conclude that there is no evidence that 2 physicians from the same practice in the same speciality can bill separately for the same patient on the same day. The policy clearly states that only one physician in the practice and submit at 99291, and as such, the other doctor will not be able to submit a 99291 and his 99292 is inelegible without it.

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  25. Now do you develop a second set of books to regive yourself back credit worked by another MT? You would have to.

    Dr. Happy, at some point you are going to need to accept that keeping a second set of books is not the only way to solve a bookkeeping problem. Pink would not need a second set of books for the situation you described. She would need to do things differently, but she can still keep one set of books.

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  26. It could be that whoever wrote this document copied the policy down from the Medicare documents, but then didn't understand it when he/she came up with an example.

    Personally, I think the writer of the example intended to illustrate that only 1 doctor in the same-speciality practice can submit a 99291, not to illustrate that both doctors can submit bills to medicare. He screwed the example up.


    Hmm. Perhaps the writer of that document was just copying this stuff, and so as not to look like he was plagiarizing the examples (about 2/3 down the page), he "enhanced" them and screwed them up by adding detail about the doctors.

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  27. Hey you, I think we've beaten a dead horse. But just to let you know regarding your statement:

    I conclude that there is no evidence that 2 physicians from the same practice in the same speciality can bill separately for the same patient on the same day.

    That's not true at all. If my partner admitted a patient with an E&M code, say a 99223 admit code and the patient decompensated later in the day and my service on the patient rose to critical care level documentation, I could also submit a 99291 under my name and get paid.

    Same patient. Same calendar day. Same group of docs, Two different docs. Both getting paid.

    FYI

    As far as no evidence, I will take the word of my coding people any day of the week.

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  28. That's not true at all.

    OK. My comment did not include all of the relevant detail. I did not think it was necessary to be so verbose in a civil discussion, and that readers would ASSUME the context of the discussion. You changed the context to come up with an example to prove me wrong. Obviously, communication will not take place in such an enviroment.

    Did you bother to read the documents I pointed you to? Did you try to see it from a different angle? If not, then communication will not take place. There is none so blind as he who will not see.

    It seems clear to me that you do not want to see what I am saying. (Dino did the same thing to you in her argument that hospitalist medicine cannot survive. She could not see your point because she would not. You will not see mine.) I guess I will have to fold.

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  29. "Pink, medical records has nothing to do with our billing company.

    Nothing at all."

    How is that so? You verbosely go on and on about what you must document in order to get paid. I'm assuming those documents/records come from somewhere.

    Or, do you not dictate at all? Do you simply rely upon the "order sets" to complete your documentation so that correct payment can be made?

    Please clarify. I'd love to understand the trickle down process from documentation to payment in your hospital setting.

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  30. Hey you. I read what you sent. I disagree with your conclusion and interpretation.

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  31. Pink. The medical records department of the hospital has nothing to do with the billing company for Happy's hospitalist group.

    I determine what my coding is. I submit my code to my billing company. My billing company submits my codes to insurance. The hospital medical records department has not part in the process.

    My billing company submits what I code. They do no audit every chart.

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  32. Pink. And I code what I document for the hospital records.

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  33. I'm a hospital Billing Specialist (I capitalized that because it makes me appear more important) for a large pulmonary practice. We can bill all day with the 99291 and the 99292's, MUST BE same doc (doesn't make sense to me, either, but you get the denial if you try to go against the grain) in the 24 hr. period. NOW, I have Docs that want to know "how much they've done" each month, and our billing system has no way to differentiate who spent 38 min. of CC and who did 67 min. on that same DOS. OMG; I am going to have to keep an Excel spreadsheet, one Doc per column, DOS down the left margin, and how many stinking minutes of 99292 each "alien" Doc added to the "primary" Doc's time for that initial 99291. It's our way of keeping a "book" on it; nothing illegal, just a way of tracking who gets more money for doing more work.

    Just a suggestion from a lowly biller. Good luck to all of you Docs, MT's and such fighting the Medicare Machine.

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  34. There is no such things as a lowly biller. Just good ones and bad ones. The Medicare machine it is.

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