Billing Critical Care and Discharge On Same Calendar Date?

Can I bill a critical care code and a discharge code on the same day?   That's a question a lot of folks finding The Happy Hospitalist are asking themselves.  I am a hospitalist with over ten years of clinical experience and years of research in evaluation and management (E/M) medicine.   I have a very short answer and one that should lay to rest any question about what code the physician should choose when they provide critical care on the date of discharge. On page 3 of 9 in  CMS document MM6740, we are told
In all cases, physicians will bill the available code that most appropriately describes the level of the services provided.
That means, if you provide critical care you should bill for critical care, regardless of whether that service was provided on the day of admission or the day of discharge. Yes, I believe the physician can and should bill for critical care even if they discharged the patient on the same date as the critical care service was provided.  But can they also bill a discharge code?  I do not believe they can. Even though CMS tells us we should bill the available code that most appropriately describes the level of services provided, I believe their rules disallow both codes on the same calendar date.   As such, physicians would be better off billing for their critical care services and not the discharge codes in these situations.   My exhaustive research on this issue failed to disway my opinion on this matter.  If there are any experts with further insight into this common scenario, I welcome your input to expand and accurately identify any misunderstandings. With that said, I think it's important to understand a few key points.  Here are a few scenarios to consider.

CRITICAL CARE WITH ADMISSION AND DISCHARGE SAME DATE


There are two possible scenarios to consider when providing admission and discharge on the same calendar date with critical care:  Critical care is provided on admission or critical care is not provided on admission.

  • SCENARIO 1:  The initial admission work does not rise to critical care criteria but then critical care is subsequently provided and discharge is then made after that on the same calendar date.  In this situation I would bill for the appropriate admit E/M charge and any related critical care charges and not bill the admit and discharge same day codes.  Remember, CMS has told us  to "bill the available code that most appropriately describes the level of services provided".  That is our mandate. 

    • CMS has previously told us that critical care and an E/M code can be billed on the same calendar date if the critical care was provided after the E/M service was provided.   Unfortunately, they do not specifically agree or disagree that an E/M code can be billed after a critical care code.  I believe, however, that this failure to provide guidance is a round-about way of saying post critical care E/M charges are not allowed on the same calendar date.   If they were allowed, I do not know why would they specifically give guidance to allowing pre critical care E/M codes but not post critical care E/M services?  I have written about this previously at the link provided just above.
    • In my opinion, that means discharge services, which are bundled into 99234-99236 codes cannot be billed in conjunction with critical care codes because the discharge services would presumable occur after the critical care service.  We are left with a scenario where a patient is admitted and discharged on the same calendar date where a physician provides critical care, but cannot bill for the discharge services.  I would bill an admit E/M code (probably initial inpatient admission codes (99221-99223) or initial hospital observation codes (99218-99220) if the documentation supports those codes) and then bill for critical care 99291.   Attach a -25 modifier to the first E/M code.   If more than 74 minutes of critical care was provided, bill for 99292 as well.  I would not bill for discharge services because no code exists to capture that service. Billing for the admit and discharge same day codes would not allow the practitioner to capture their critical care service and CMS has told us to "bill the available code that most appropriately describes the level of service provided.  The bundled admit and discharge codes 99234-99236 would not be appropriate in this situation.  In this scenario, the work you do discharging the patient is free, but the RVU value of the critical care is still higher using an admit E/M code and critical care code than using the bundled admit and discharge code alone.   
    • Remember, do not bill for critical care time on the discharge work (unless you are transferring the patient to another institution) as the patient would not presumably be critically ill during your discharge decision.  In a previous discussion about billing critical care for family meetings in the ICU the following statement was discussed:
      • Critical care CPT codes 99291 and 99292 include pre and post service work. Routine daily updates or reports to family members and or surrogates are considered part of this service.  In my opinion, billing for discharge work after critical care would have to fall into the "include pre and post service work" category because no other codes apply.
    • It is my opinion, if a physician is transferring a critically ill patient to another institution, discharge work should be considered part of the critical care time as the provider will be writing orders, making medication decisions, communicating their patient's condition with other healthcare providers and providing a safe transition to a higher level of care, as long as that work is provided in the immediate vicinity of the patient or the patient's unit.  

  • SCENARIO 2:  The initial admission work does rise to critical care criteria and discharge is subsequently made on the same calendar date.  In this situation I would bill all appropriate critical care charges (99291 and or 99292) and not bill the admit and discharge same day codes.  Remember, CMS has told us  to "bill the available code that most appropriately describes the level of services provided".  That is our mandate.   Billing admit and discharge codes in this scenario would not allow the physician to capture critical care resources and would not be appropriate.

    • As I reviewed above, do not include your discharge work in your critical care time, unless that discharge work involves continued critical care decision making during a transfer to a another institution.    Providers would have a hard time justifying to an auditor that routine discharge time was of a critical nature.  
    In either scenario, a single critical care code provides a higher relative value unit (RVU) compensation than any of the same day admit and discharge codes 99234-99236. Thus, whether the provider bills only critical care or an E/M code in addition to critical care code(s) they have the ability (and the right) to collect a higher payment for work that most appropriately describe the level of service provided.   Under neither scenario do I believe the inpatient discharge codes 99238 or 99239 or observation discharge code 99217 be used or considered.

    Some readers may be wondering how a patient could be critical and then be discharged on the same calendar date.  As hospitalists, we see many patients who present with critical illness, or become critical but because of excellent care or rapid reversal of the critical situation, are able to be discharge on the same calendar date.  Some of this has to do with when the clock starts running.  Remember, Medicare and most insurances use the midnight-to-midnight calendar date rule  when determining same day admit and discharges.  If a patient came in at 12:01 am, they have until 11:59 pm that same day to be discharged as a same day admit and discharge.  23 hours and 59 minutes is a long time for some critical conditions to improve. 

    For example, patients with seizures who need airway support on a ventilator are critically ill on admission.  Drug overdose patients with respiratory demise may respond rapidly to reversal agents.   Patients with hyperglycemia or hypoglycemia may present with critical illness in the form of DKA, seizures, unresponsiveness, encephalopathy or other critical illness, but may respond rapidly to treatment.  Just because a patient is treated appropriately and aggressively and shows rapid improvement does not mean their critical illness should be discounted.  If a provider provides critical care, they should bill for critical care, regardless of how quickly they respond to treatment.


    CRITICAL CARE WITH ADMISSION AND DISCHARGE DIFFERENT DATE


    How should critical care be billed when the admission and discharge occur on different dates and the critical care is provided on the date of discharge.  Regardless of whether the patient is inpatient or observation status if critical care is provided on the date of discharge, bill for the critical care service but do not bill for the discharge code.  Any work provided on discharge after the critical care charge should not be billed as critical care time, unless, the discharge services involved transfer to another institution.  I detailed this reasoning above.  Remember, only bill for critical care time when the patient is critically ill.  An auditor will ask for your money back if you're billing for a discharge summary on a stable patient going to a nursing home.  The discharge work you provide on stable patients will be included in your critical care code(s).  From an RVU perspective, critical care 99291 pays more than double the greater than 30 minute discharge code 99239.   These scenarios can and do happen that result in critical care that requires immediate stabilization at the bedside that can allow for discharge later in the day.  Providers have a right and an obligation to bill the available code that most appropriately describes the level of the services provided.

    WHY NOT BILL 99291 AND 99238 OR 99291 AND 99239 ON DATE OF DISCHARGE?


    I spent a great deal of time researching why discharge codes could not be billed as separate and identifiable services after critical care was provided on any given calendar date.  I was surprised to find very little on this common scenario.  Some scattered resources suggested billing the discharge after the critical care and using the -25 modifier.   Some resources suggested there was no explicit exclusion by CMS that said both services could not be billed and paid on the same date.  CMS says, "in all cases, physicians will bill the available code that most appropriately describes the level of the services provided." 

    Why would they allow E/M charge before a critical care code but not a discharge code after?  CMS specifically states they allow an E/M code before a critical care code.  I would presume because they don't specifically address billing an E/M code after a critical care code on the same calendar date, that they do not allow payment for that scenario.  I wish they would provide better clarity in their manuals.

    Perhaps it has to do with the AMA definition of the discharge codes.  The CPT® manual states that discharge codes 99238 and 99239 are to be used by physicians to report all services provided to a patient on the date of discharge.  CMS and the AMA do not always agree on their definitions, but I believe if physicians billed the discharge code, then the critical care service would be bundled into the discharge code and the critical care service would be denied.  The critical care codes pay much more than the discharge codes.   Getting paid for critical care and providing uncompensated discharge work is a better business decision.  Alternatively, the physician can always submit a 99291 in combination with a 99238 or 99239 or 99217 using a -25 modifier and see what happens.  The worst that can happen is that it can get denied.  For a scenario that happens with relative frequency, I'm surprised of so few resources available on the internet for review.

    I provide a detailed database of free E/M and CPT® lectures for physicians and other non-physician practitioners.  I am a hospitalist with over ten years of clinical experience.  My hospitalist resource center also has important information for all clinicians to review.


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