Medicare’s Critical Care Services Policy Gets a Transfusion
Here’s what you need to know to stay in compliance.
Part 1 of a 2-part series
By Elin Baklid-Kunz, MBA, CPC, CCS
It’s not easy keeping current with Medicare’s changing critical care services policy. Recent changes include the July 1, 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 addition to updating and defining critical care services and clarifying how to correctly bill for these services, the CR replaces the outdated blood draw CPT® code 36540 with the new 2008 CPT® code 36591 Collection of blood specimen from a completely implantable venous access device, and includes several clinical examples for critical care services. The transmittal includes clarifications for the following:
- Medically necessary services
- Full physician attention
- Counting the hours of critical care billing
- Performance of other E/M services on the same day as critical care services
- Group practice issues
- Services by a qualified non-physician practitioner (NPP)
- Bundled procedures
- Global surgery issues
- Ventilation management
- Teaching physician issues
- Physician time related to services off the unit/floor, split/shared services, unbundled procedures, inappropriate use of time and family counseling and discussions
Adult Critical Care Services
Critical care services are E/M services subject to specific Medicare coding, documentation, and payment guidelines in addition to the American Medical Association’s (AMA) CPT® requirements. This update adds the definition of critical care services to the CPT® manual.
“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 requires high complexity decision-making to assess, manipulate, and support vital system function(s) 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-like conditions; and
- renal, hepatic, metabolic and/or respiratory failure.
Clinical Condition and Treatment Criterion
The updated policy clarifies that critical care services must be reasonable and medically necessary and encompass both the treatment of “vital organ failure” and “prevention of further life threatening deterioration in the patient’s condition.” Providing medical care to a critically ill patient is not automatically deemed a critical care service. The following are a few of the examples in CR 5993 that clarify what constitutes as critical care services:
Medical conditions that may warrant critical care services: “An 81-year-old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and vasopressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent.”
Medical conditions that may not warrant critical care services: “Daily management of a patient on chronic ventilator therapy unless the critical care is separately identifiable from the chronic long-term management of the ventilator dependence.”
Patients who may not satisfy Medicare medical necessity criteria, or do not meet critical care criteria or do not have a critical care illness or injury and are not eligible for critical care payment: “Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (eg, drug toxicity or overdose).”
If the services are reasonable and medically necessary but do not meet the criteria for critical care services, then you should re-code them as other appropriate E/M services (eg, subsequent hospital care, CPT® codes 99231-99233). Additional clinical examples of critical care services can be found in Appendix C of the CPT® manual.
Supervision is Mandatory
Critical care services require a physician’s direct supervision and management of life and organ supporting interventions, which may require frequent manipulation by that physician. The physician must devote full attention to the patient and cannot render E/M services or other services to another patient during the same time period. The reported duration of critical care services is the time the physician spent evaluating, providing care, and managing the critically ill or injured patient’s care. That time must be spent at the immediate bedside or elsewhere on the floor or unit so the physician is immediately available to the patient.
Follow the Rules
Qualified NPPs may provide and report payment for critical care services under their National Provider Identifier (NPI) when the services meet the definition and requirements of critical care services. The provision of critical care services must be within the scope of practice and follow requirements for the state where the qualified NPP practices and provides the service(s). The updated policy is explicitly clear that Medicare’s Split/Shared Visit Policy does not apply to critical care services. Unlike other reported E/M services where a split/shared service is allowed, the reported critical care service should reflect the patient’s evaluation, treatment, and management by an individual physician or qualified NPP and should not reflect the combined service between a physician and a qualified NPP.
CPT® bundles professional services associated with certain procedures into critical care for adults and should not be separately reported. These procedures include the following:
Interpretations of cardiac output measures – 93561 Indicator dilution studies such as dye or thermal dilution, including arterial and/or venous catheterization; with cardiac output measurement (separate procedure) and 93562 Indicator dilution studies such as dye or thermal dilution, including arterial and/or venous catheterization; subsequent measurement of cardiac output
Chest X-rays professional component – 71010 Radiologic examination, chest; single view, frontal, 71015 Radiologic examination, chest; stereo, frontal and 71020 Radiologic examination, chest, two views, frontal and lateral
Blood gases and information data stored in computers – 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report, 99090 Analysis of clinical data stored in computers (eg, ECGs, blood pressures, hematologic data) and 82800-82810 (eg, ECGs, blood pressures, hematologic data—CPT® 99090)
Pulse oximetry – 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination, 94761 Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise), and 94762 Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure)
Gastric intubation – 43752 Naso- or oro-gastric tube placement, requiring physician’s skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report) and 91105 Gastric intubation, and aspiration or lavage for treatment (eg, for ingested poisons)
Temporary transcutaneous pacing – 92953 Temporary transcutaneous pacing
Ventilation management – 94002–94004, 94660 Continuous positive airway pressure ventilation (CPAP), initiation and management, and 94662 Continuous negative pressure ventilation (CNP), initiation and management
Vascular access procedure – 36000 Introduction of needle or intracatheter, vein, 36410 Venipuncture, age 3 years or older, necessitating physician’s skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture), 36415 Collection of venous blood by venipuncture, 36591, and 36600 Arterial puncture, withdrawal of blood for diagnosis
No other procedure codes are bundled into the critical care services. Other medically necessary procedure codes not listed above should be reported separately.
Separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and reported with modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. The time spent performing procedures not bundled into critical care may not be included and counted toward critical care time.
Time spent performing the pre-, intra-, and post-procedure work of these unbundled services should be excluded from the determined time spent providing critical care. Endotracheal intubation is one example.
Some services separately billable with critical care include endotracheal intubation, insertion/placement of Swan Ganz, cardiopulmonary resuscitation, and central venous lines, which are CPT® codes:
31500 Intubation, endotracheal, emergency procedure
93503 Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes
92950 Cardiopulmonary resuscitation (eg, in cardiac arrest)
36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older
Critical Care is a vast topic. Look for an upcoming Coding Edge article where we discuss 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.
CMS Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.12 www.cms.hhs.gov/manuals/downloads/clm104c12.pdf
CMS Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, §30E www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf
CMS Transmittal 1548, CR 5993, July 9, 2008
CMS MLN Matters MM5993, CR 5993, July 9, 2009
AMA CPT® Manual, Professional Edition 2008
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