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INFUSING Critical Care Services Policy

Part 2 of a 2-part series

By Elin Baklid-Kunz, MBA, CPC, CCS
Last month, we discussed Change Request (CR) 5993, which revises the Medicare Claims Processing Manual, Publication 100-04, Chapter 12, §30.6.12 “Critical Care Visits and Neonatal Intensive Care (Codes 99291-99292).” This revision updates previous critical care payment policy language and adds general Medicare evaluation and management (E/M) payment policies for critical care services. In part one of our series we covered adult critical care services, clinical condition and treatment criterion, bundled procedures, and modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service usage. This month, we’ll talk about critical care in regard to physician documentation and time, concurrent care, and services provided during a procedure’s global period. We’ll also provide you with a handy checklist to determine if documentation supports critical care services.

Physician Documentation

Adult critical care services are time-based, so the critical care progress note for each date and encounter entry must contain the total time spent with the patient providing critical care services directly related to the patient’s care. For example, “total critical care time, excluding procedures, 1 hour and 20 minutes.” Each daily note should include the specific diagnoses supporting critical illness and details of the patient’s condition and care to support medical necessity and the ongoing critical illness and high complexity decision making.
Critical care may be provided on multiple days, even if no changes are made to the patient’s treatment, and provided the patient’s condition continues to require the level of physician attention described previously.

Teaching Physician Documentation and Time

For time-based procedure codes, such as critical care, the teaching physician must be present for the entire period of time that the claim is submitted for. 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.

  • Teaching time may not be counted towards critical care time. The teaching physician cannot bill for the resident’s time spent with the patient (in the teaching physician’s absence). Only time that the teaching physician spends alone with the patient and spent together with the resident and patient, can be counted toward critical care time.

A combination of the teaching physician’s documentation and the resident’s documentation may support critical care services. If all requirements for critical care services are met, the teaching physician documentation may tie into the resident’s documentation. The teaching physician may refer to the resident’s documentation for specific patient history, physical findings, and medical assessment.

However, the teaching physician medical record documentation must provide substantive information including

  • the teaching physician’s time spent providing critical care,
  • the patient was critically ill during the time the teaching physician saw the patient,
  • what made the patient critically ill, and
  • Ì  the nature of the treatment and management provided by the teaching physician.

The CR provides the following documentation examples for teaching physicians:

  • Unacceptable documentation: “I came and saw (the patient) and agree with (the resident).”
  • Acceptable documentation: “Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident’s documentation and I agree with the resident’s assessment and plan of care.”

Family Members’ or Surrogate Decision Maker’s Time

To count the time spent with family members or surrogate decision makers as critical care time Medicare requires the following documentation in the physicians progress note for that day:
1. The patient was unable or incompetent to give history and/or make treatment decisions.
2. The necessity of the discussion (eg. “unable to obtain history from another source,” or “the patient was deteriorating so rapidly I needed to discuss treatment options with the family immediately”).
3. The treatment decisions for which the discussion was needed.
4. The substance of the discussion as it related to the treatment decision.
The physician’s progress note should also link family discussion to a specific treatment issue and explain why the discussion was necessary on that day. Telephone calls to family members or surrogate decision makers must meet the same conditions as a face-to-face meeting. All other family discussions, no matter how lengthy, may not be counted towards critical care time.

Critical Care Services Units

If the physician’s total duration of critical care on a given day is less than 30 minutes, the appropriate E/M code should be used. In the hospital setting, it is expected that the level 3 subsequent hospital care code 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history; a detailed examination; medical decision making of high complexity is used most often.
It should be used only once per day even if the time spent by the physician is not continuous on that date.
CPT® code 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes is used to report the services of a physician providing constant attention to a critically ill patient for a total of 30 to 74 minutes on a given day. Only one unit of CPT® code 99291 may be billed by a physician for a patient on a given date.
The initial critical care time billed as CPT® code 99291 must be met by a single physician or qualified non-physician practitioner (NPP). This may be performed in a single period of time or be cumulative by the same physician on the same calendar date.
Medicare does not pay for two physicians billing critical care at the same time. Only one physician can bill for critical care during any one single time period. However, but both physicians can bill for critical care provided on the same day at different times. If the claim is denied, the claim may be re-submitted with an explanation and documentation that the critical care was provided at different times. Consider documenting the exact stop and start time for critical care, in addition to the total time.
Same specialty physicians within the same group practice bill and are paid as though they are a single physician and would not each report CPT® 99291 on the same service date.
When the physicians’ group provides care unique to his/her individual medical specialty and manages at least one of the patient’s critical illnesses or critical injuries, the initial critical care service may be payable to each.
If a different physician or qualified NPP within a group provides staff coverage or follow-up after the first hour of critical care services was provided on the same calendar date by the previous group physician or NPP, bill the subsequent visits by the covering physician or NPP in the group using the critical care add-on code 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).

Code 99292 for Additional 30 Minutes

For subsequent critical care visits performed on the same calendar date report using CPT® code 99292.
Report code 99292 for physician’s services providing constant attention to the critically ill patient for up to 30 minutes beyond the first 74 minutes of critical care on a given day.
Note: Be aware of physicians who report 99292 when they provide 65 minutes of critical care and who confuse 99291 for the first hour up to 60 minutes rather than 74 minutes.
The service may represent aggregate time met by a physician or physicians in the same group practice with the same medical specialty to meet the minutes duration required for CPT® code 99292. The aggregated critical care visits must be medically necessary and each aggregated visit must meet the critical care definition to combine the times.

Report Critical Care Correctly

Correctly report time spent on critical care services using this table.

Total Duration of Critical Care Code(s)
Less than 30 minutes 99232 or 99233 or other appropriate E/M code
30-74 minutes 99291 x 1
75-104 minutes 99291 x 1 and 99292 x 1
105-134 minutes 99291 x 1 and 99292 x 2
135-164 minutes 99291 x 1 and 99292 x 3
165-194 minutes 99291 x 1 and 99292 x 4
194 minutes or longer 99291–99292 as appropriate (per above illustrations)

Consider the following example from the transmittal:
A patient arrives in the emergency department (ED) in cardiac arrest. The ED physician provides 40 minutes of critical care services. A cardiologist is called to the ED and assumes responsibility for the patient, providing 35 minutes of critical care services. The patient stabilizes and is transferred to the CCU. In this instance, the ED physician provided 40 minutes of critical care services and reports only the critical care code (CPT® code 99291) and does not also codes for ED services. Using CPT® code 99291, the cardiologist may also report the 35 minutes of critical care services provided in the ED. For additional critical care services by the cardiologist in the CCU (on the same calendar date), use 99292 or another appropriate E/M code depending on the clock time involved.

Critical Care and Concurrent Care

Concurrent care is when more than one physician renders services more extensive than consultative services during a time period. Critically ill or injured patients may require the care of more than one physician medical specialty, but the services provided by each physician must be medically necessary and not provided during the same time period. Concurrent care by more than one physician (generally representing different physician specialties) is payable if

  • services all meet critical care requirements;
  • are medically necessary; and
  • are not duplicative.

Physician specialty means the primary specialty by which the physician bills Medicare and is known to the contractor that adjudicates the claims.
While more than one physician may provide critical care services to a patient during the critical care illness or injury, each physician must manage one or more critical illnesses or injury(ies) in whole or in part.

Other E/M Services Provided on Same Day

Physicians are advised to submit documentation supporting a claim when critical care is reported on the same calendar date as other E/M services are provided to a patient by the same specialty physician or physicians in a group practice.
If there is a hospital or office/outpatient E/M service furnished early in the day and at that time the patient does not require critical care, but the patient requires critical care later in the day, both critical care and the E/M service may be paid. Note that hospital ED services are not paid for on the same date as critical care services when provided by the same physician to the same patient.
If critical care is required when the patient presents to the ED, only critical care codes 99291-99292 may be reported. ED codes will not be paid for the same day as critical care services, and should not be reported.

Services Provided During Procedure’s Global Period

When the patient suffers trauma or burns, Medicare policy allows separate payment to the surgeon for postoperative critical care services during the surgical global period. When the surgeon provides critical care services during the global period, for reasons unrelated to the surgery, these are separately payable if the patient is critical ill and requires constant physician attendance. Such patients are potentially unstable or have conditions that could pose a significant threat to life or risk of prolonged impairment. For payment of these services, documentation reflecting that the critical care was unrelated to the specific anatomic injury or the general surgical procedure must be submitted. An ICD-9-CM code in the range 800.0-959.9 (except 930-939) which clearly indicates that the critical care was unrelated to the surgery is acceptable documentation.

  • Preoperatively, codes 99291/99292 and modifier 25 must be used.
  • Postoperatively codes 99291/99292 and modifier 24 Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period must be used.

Modifier 24 is added to indicate critical care unrelated to the previous surgery and modifier 25 indicates critical care related to the previous surgery.
Remember that 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 provided treatment meet the critical care requirements.
CMS’ Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.12
CMS’ Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, §30E
CMS Transmittal 1548, CR 5993, July 9,2008
CMS MLN Matters MM5993, CR 5993, July 9, 2009
American Medical Association’s Current Procedural Terminology (CPT®) Manual, Professional Edition 2008


Determine if Documentation Supports Critical Care

Keep this handy checklist to help you determine if documentation supports critical care service:
o Does the patient have acute impairment of one or more organ systems and have a high probability of imminent or life threatening deterioration?
o Did the physician provide high-complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple organ system failure and/or prevent further life threatening deterioration in the patient’s condition.
o Is time specifically documented? 99291 30-74 minutes
o Is time specifically documented? 99292, additional 30 minutes; 75 to 104 minutes
o Is the documented time reasonable considering the documented work performed?
o If the time includes time spent with family, was the family member operating as surrogate decision-maker because the patient is unable to make decisions?
o Does the family member discussion include a summary of the discussion?
o Bundled procedures (included in critical care time) are not billed separately.
o Does the documented critical care time exclude the time spent performing procedures where separate payment is made?
o If the physician assistant (PA) or nurse practitioner (NP) performed critical care, is this billed under the non-physician practitioner’s (NPP’s) number for Medicare? The shared visit rule does not apply to critical care services.
o  Time spent teaching the resident is excluded. Was the teaching physician present for the entire reported time period?

Evaluation and Management – CEMC

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