Answers to All of Your E/M Service Critical Care Questions

Q1: Can a physician and an NPP of the same specialty and the same group are both bill critical care code 99291 if documenting the critical time for the patient? Could they bill separately for a patient’s critical care, each reporting 99291?

A1: Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient. For each medical encounter, the physician’s progress notes must document the total time that critical care services are provided. Unlike other E/M services, critical care services reflect one physician’s (or qualified non-physician practitioner’s) care and management of a critically ill or critically injured patient for the specified reportable period of time. You cannot report a split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) as a critical care service. The critical care service reported should reflect the evaluation, treatment and management of the patient by the individual physician or qualified non-physician practitioner and not represent a split/shared combined service.

Critically ill or injured patients may require the care of more than one physician medical specialty, but keep in mind that the critical care services provided by each physician must be medically necessary. Medicare will pay for non-duplicative, medically necessary critical care services provided by 1) physicians from the same group practice; or 2) from different group practices to the same patient.

Note: Physician specialty means the self-designated primary specialty by which the physician bills Medicare and is known to the carrier who adjudicates the claims. Physicians in the same group practice who have different medical specialties may bill and be paid without regard to their membership in the same group. For example, if a cardiologist and an endocrinologist are group partners and the critical care services of each are medically necessary and not duplicative the critical care services may be reported by each regardless of their group practice relationship.

The initial critical care time (billed as CPT code 99291) must be met by a single physician or qualified NPP. This may be performed in a single period of time or be cumulative by the same physician on the same calendar date. A history or physical examination performed by one group partner for another group partner in order for the second group partner to make a medical decision would not represent critical care services.

Q2: Are there phrases that providers might use that would negate being able to bill critical care? (i.e. "stable," "improving") How could they document to prove the patient is still critical if these words are used?

A2: If you find that a provider’s statements might be misconstrued by an auditor, discuss the case with them to determine what their thought processes are and ask questions.

To report 99291/99292, both the illness or injury and the treatment being provided must meet the critical care requirements, as previously described. Clinical reassessments and documentation must support the critical care time aggregated, and should include:

• a description of all of the physician’s interval assessments of the patient’s condition;
• any impairments of organ systems based on all relevant data available to the physician (i.e. symptoms, signs, and diagnostic data);
• the rationale and timing of interventions; and the patient’s response to treatment.

Q3: A provider documents critical condition as hypercapnic respiratory failure and the treatment plan is to begin extubating/weaning ventilation. If the patient is being weaned from critical care interventions, can this still be billed as a critical care service?

A3: Critical care is defined as a physician's’ direct delivery of 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 to treat single, or multiple, vital organ system failure; and/or to prevent further life threatening deterioration of the patient’s condition.

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.

Although it typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present. You should speak with your provider(s) about such information.

Critical care services must be reasonable and medically necessary. As explained above, critical care services encompass both the treatment of “vital organ failure” and “prevention of further life threatening deterioration in the patient’s condition.” Therefore, delivering critical care in a moment of crisis, or upon being called to the patient’s bedside emergently, is not the only requirement for providing critical care service. Treatment and management of a patient’s condition, in the threat of imminent deterioration; while not necessarily emergent, is required.

Q4: As far as documentation goes, is total time spent on critical care ok per date, or are START/STOP times required.

A4: There is no regulatory guidance from Medicare for start/stop times related to critical care.

Critical care is a time- based service. Payment for critical care services is not restricted to a fixed number of hours, days, or physicians (on a per-patient basis) when such services meet medical necessity; and time counted toward critical care services may be continuous clock time or intermittent in aggregated time increments (e.g. fifty minutes of continuous clock time or five ten minute blocks of time spread over a given calendar date).

Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient. For each medical encounter, the physician’s progress notes must document the total time that critical care services are provided.

However, you do need to consider the time of unbundled services. Services such as endotracheal intubation (CPT code 31500) and the insertion and placement of a flow directed catheter e.g., Swan-Ganz (CPT code 93503) are not bundled into the critical care codes. Therefore, separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and it was reported with modifier - 25. The time spent performing the pre, intra, and post procedure work of these unbundled services, e.g., endotracheal intubation, should be excluded from the determination of the time spent providing critical care.

Q5: Is there any scenario where an E/M code and a critical care code can both be reported on the same date. For example, same provider gives critical care and also does an inpatient admission.

A5: Yes, but not for emergency department services (99281-99285) by the same physician on the same date of service.

Note: 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 (significant, separately identifiable evaluation and management services by the same physician on the day of the procedure) should be appended to the critical care code when applicable in this situation.

Q6: Could you please go over the split shared services with provider and NPP?

A6: Only one physician can bill for critical care during any one single period of time. Unlike other E/M services, critical care services reflect one physician’s (or qualified non-physician practitioner’s) care and management of a critically ill or critically injured patient for the specified reportable period of time. You cannot report a split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) as a critical care service. The critical care service reported should reflect the evaluation, treatment and management of the patient by the individual physician or qualified non-physician practitioner and not represent a split/shared combined service.

Q7: Define covering or staffing physician please?

A7: Physicians assigned to a critical care unit (e.g., hospitalist, intensivist, etc.) may not report critical care for patients based on a ‘per shift’ basis.

Q8: Does the Medicare Manual indicate that 99291, which says first 30-74 minutes per date I am thinking only one (1) 99291 per patient per date?

A8: You can only use 99291 once per calendar date to bill for care provided for a particular patient by the same physician or physician group of the same specialty. However, that does not negate critical care being provided to the same patient by another provider of a different specialty and/or a different group.

Q9: Does the physician have to make a statement in the critical care note as to why the patient needs critical care?

A9: A “statement” is not necessary. Critical care is defined as a physician's’ direct delivery of 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 to treat single, or multiple, vital organ system failure; and/or to prevent further life threatening deterioration of the patient’s condition.

Q10: If a physician sees a patient in the morning, charges a consult, and later in the afternoon the patient crashes and charges critical care, can you charge both using a modifier?

A10: There is no modifier necessary to report a different E/M service on the same date prior to, or after critical care services are performed. However, an emergency department E/M (99281-99285) would not be reported with the critical care codes (99291, 99292).

Q11: If the patient presents with an exacerbation CHF or COPD would that qualify for critical care?

A11: Only the physician can provide the determination of the patient being critical ill/injured and reasonable and medically necessary services need to be provided for the care of the patient.

Q12: Medicare and CPT guidelines differ on unbundling procedures included in critical care time. As best practice, which guidelines do you use?

A12: We are not aware that Medicare and CPT differ on unbundling of procedures included in critical care time.

Q13: Palliative Care permitted as critical care billing?

A13: You will need to check with your Medicare Administrative Contractor (MAC). For example, CGS 2014 Critical Fact Sheet states: “Palliative care services CANNOT be submitted with critical care codes, as the palliative care does not meet the definition of critical care.”

Q14: The condition of the patient determines if Critical Care codes are used rather than the Place of treatment (E/R or Critical care unit). Is that correct?

A14: Yes, that is correct. The Medicare Claims Processing Manual explains this:

“Providing medical care to a critically ill, injured, or postoperative 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:

“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).”

Q15: The day the patient gets transferred to the floor - can we still bill critical care- example: patient was evaluated and at the end of evaluation, MD states ok to transfer to floor, but they document CCT should this just be an EM?

A15: Critical care is defined as a physician's’ direct delivery of 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 to treat single, or multiple, vital organ system failure; and/or to prevent further life threatening deterioration of the patient’s condition.

• 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

Although it typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present. You should speak with your provider(s) about such information.

Critical care services must be reasonable and medically necessary. As explained above, critical care services encompass both the treatment of “vital organ failure” and “prevention of further life threatening deterioration in the patient’s condition.” Therefore, delivering critical care in a moment of crisis, or upon being called to the patient’s bedside emergently, is not the only requirement for providing critical care service. Treatment and management of a patient’s condition, in the threat of imminent deterioration; while not necessarily emergent, is required.

CPT code 99292 (critical care, each additional 30 minutes) is used to report each additional 30 minutes beyond the first 74 minutes of critical care. It may also be used to report the final 15 - 30 minutes of critical care on a given date. Critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not separately payable. Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E/M code such as subsequent hospital care.

Q16: What is the key difference between charging Facility Critical Care vs Professional billing of critical care?

A16: For commercial insurance, codes 99291-99292 might be utilized based upon your payer contract. For Medicare we would advise that you consult the most recent guidance under the 2016 Final Rule for the Hospital Outpatient Prospective Payment System (OPPS) to become familiar with different code sets from the HCPCS manual, variations of combined services under the Ambulatory Payment Classification (APC) system, and activation of Trauma Care Services. The number of items to make note of are too vast to discuss here in this FAQ on physician coding of critical care services.

Q17: When a physician provides critical care and then later that same day the patient passes away. Can the provider bill for both CC and a 99238 for pronouncement of death?

A17: There is no regulatory guidance from CPT or CMS which would preclude billing for both services. The Medicare Claims Processing Manual, Chapter 12, Section 30.6.9. Payment for Inpatient Hospital Visits – General, A. Hospital Visit and Critical Care on the Same Day, provides the following information:

“When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service. Hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.

During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 – 99233.

Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.

Physicians and qualified nonphysician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims. The retained documentation shall support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for the same patient on the same calendar date as other E/M services.”

Q18: Can we assume that intensivists are always providing critical care?

A18: Not for CPT or CMS coding, documentation, billing, medical reasonableness, or medical necessity purposes. Please reference to references for further guidance.

Q19: You can bill CC for time spent on phone calls to decision makers, correct?

A19: 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. However, time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options (as described in CPT), may be counted toward critical care time when these specific criteria are met:

• The patient is unable or incompetent to participate in giving a history and/or making treatment decisions; and
• The discussion is necessary for determining treatment decisions. For such family discussions, the physician should document:
• The medically necessary treatment decisions for which the discussion was needed;
• That the patient is unable or incompetent to participate in giving history and/or making treatment decisions;
• The necessity to have the discussion (e.g., "no other source was available to obtain a history" or "because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family"; and
• A summary in the medical record that supports this medical necessity.

Telephone calls to family members and or surrogate decision-makers may be counted towards critical care time, only if they meet the same criteria as described in the aforementioned paragraph. Further, no other family discussions (no matter how lengthy) may be additionally counted towards critical care.

Q20: As a nurse, my concept of critical care and medical necessity is that provider is called urgently to bedside due to changing status. Some here, however, feel that as long as the patient continues in a state of imminent decline, that even rounding visits can fit critical care guidelines as the patient IS on verge of imminent decline or in some type of respiratory or cardiogenic failure and they are providing critical care decision making and complexity of care.

A20: For commercial and government coding, documentation, billing, medical reasonableness, and medical necessity, please understand the following information found in both the CPT manual and CMS-referenced regulatory guidance:

Critical care is defined as a physician's’ direct delivery of 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 to treat single, or multiple, vital organ system failure; and/or to prevent further life threatening deterioration of the patient’s condition.

• 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.

Although it typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present. You should speak with your provider(s) about such information.

Critical care services must be reasonable and medically necessary. As explained above, critical care services encompass both the treatment of “vital organ failure” and “prevention of further life threatening deterioration in the patient’s condition.” Therefore, delivering critical care in a moment of crisis, or upon being called to the patient’s bedside emergently, is not the only requirement for providing critical care service. Treatment and management of a patient’s condition, in the threat of imminent deterioration; while not necessarily emergent, is required.

References:

1. Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), Section 30.6.12. (Critical Visits and Neonatal Intensive Care Codes (99291-99292), https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
2. Medicare Claims Processing Manual, Chapter 12, Section 30.6.9. Payment for Inpatient Hospital Visits – General, A. Hospital Visit and Critical Care on the Same Day, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
3. Medicare Learning Network Matters Number 5993, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm5993.pdf
4. Ten Commandments of Coding Critical Care in the ER, AAPC blogpost by Holly J. Cassano, CPC, https://www.aapc.com/blog/24587-ten-commandments-of-coding-critical-care-in-the-er/
5. Critical Care Fact Sheet from CGS Administrators, LLC, 2014, https://www.cgsmedicare.com/partb/mr/PDF/critical_care_fact_sheet.pdf