Revisit Critical CareReporting for Multiple Providers

Revisit Critical CareReporting for Multiple Providers

Know when you may report critical care on the same date of service.

In the article “Critical Thinking for Critical Care Services” (June 2015, pages 26-28), the author advises, “Only one physician may bill for a given time of critical care, even if multiple providers simultaneously care for a critically ill or injured patient.”

This statement does not mean that only one physician may report critical care for a given date of service. Under the Centers for Medicare & Medicaid Services’ (CMS) rules, more than one physician or other qualified healthcare professional may report critical care services on the same date of service, as long as the time intervals claimed do not overlap.

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Example: Two physicians provide critical care for the same patient on the same day of service. The first physician provides critical care to the patient between 12 p.m. and 1:30 p.m. The second physician provides critical care to the same patient on the same day between
6 p.m. and 7:30 p.m.

Pub. 100-04, Medicare Claims Processing Manual, chapter 12, section 30.6.12(I) confirms, “Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time.” [emphasis added]

Reporting Depends on Same
or Different Provider Group

If the two physicians are unrelated (i.e., are part of different groups) and provide medically necessary critical care at different times on the same date of service, each physician may report his or her individual service, applying time-based critical care codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and +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), in the usual manner.

Reporting requirements change if the two providers are members of the same group practice and specialty. CMS Transmittal 2636 explains, “For the same date of service only one physician of the same specialty in the group practice may report CPT code 99291 with or without CPT code 99292, and the other physician(s) must report their critical care services with CPT code 99292.”

Per the Medicare Claims Processing Manual, “The initial critical care time, billed as CPT code 99291, must be met by a single physician or qualified NPP.” Additional critical care time, as reported using 99292, “may represent aggregate time met by a single physician or physicians in the same group practice with the same medical specialty.”

To illustrate, the Medicare Claims Processing Manual provides this example:

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.

All services are billed as if provided by a single provider because
Medicare payment policy requires physicians in the same group practice who are in the same specialty to bill and to be paid as though each were the single physician.

When Providers Might Bill Separately 

If two physicians or other qualified healthcare professionals within the same group, but of different specialties, provide critical care to the patient on the same date of service, each provider might be able to bill separately. The Medicare Claims Processing Manual explains:

When the group physicians are providing care that is unique to his/her individual medical specialty and managing at least one of the patient’s critical illness(es) or critical injury(ies) then the initial critical care service may be payable to each. …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.

If the care provided is not unique to each specialist, however, you must combine the cumulative critical care time and report a single service. As stated in the Medicare Claims Processing Manual, “… if a physician or qualified NPP within a group provides ‘staff coverage’ or ‘follow-up’ for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the ‘covering’ physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292.”

Resources:

Pub. 100-04, Medicare Claims Processing Manual, chapter 12, section 30.6.12(I)


 

John Verhovshek, MA, CPC, is managing editor at AAPC and a member of the Hendersonville-Asheville, N.C., local chapter.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

2 Responses to “Revisit Critical CareReporting for Multiple Providers”

  1. Lisa Henry says:

    “As stated in the Medicare Claims Processing Manual, “… if a physician or qualified NPP within a group provides ‘staff coverage’ or ‘follow-up’ for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the ‘covering’ physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292.” …. I can Not get my Medicare contractor to pay in this situation. The denial states that the 99292 can not be processed without the primary code, 99291. The 99291 has in fact been processed on a separate claim due to charge entry for individual physicians. I have sent additional documentation of medical records, the paid EOB for the 99291, and a copy of Pub. 100-04, Medicare Claims Processing Manual, chapter 12, section 30.6.12(I). I don’t know what else to do. Any suggestions?

  2. LISA HENRY says:

    I am having difficulty getting my Medicare contractor to pay 99292 when another physician in the same practice/specialty has billed the 99291 on the same day. The denial states “COB15: This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.” I have submitted supporting documentation: the medical record, a copy of the paid EOB for the 99291 and a copy of Pub. 100-04, Medicare Claims Processing Manual, chapter 12, section 30.6.12(I). I still get the same denial. Any suggestions on getting these claims paid correctly the first time?

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