The Weirdest Thing About Critical Care Coding
Critical care coding is complex. You need to be certain that documentation supports that the patient has a critical illness or injury. You must be sure that the time reported as critical care does not include separately-billable services. But critical care reporting is truly exceptional for one reason: critical care 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) is the only add-on code that Medicare allows you to report without a primary code.
To be clear, you’d only report 99292 without its primary code 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes if:
- You are reporting services to a Medicare payer; and,
- Two or more physicians of the same specialty in a group practice provide critical care services to the same patient on the same date of service.
The Critical Care Coding Exception
These critical care coding guidelines are laid out in CMS Transmittal 2636, Change Request 7501, as follows:
The Internet Only Manual, Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.12(I) requires a provider to report CPT code 99292 … without its primary code CPT code 99291 …if two or more physicians of the same specialty in a group practice provide critical care services to the same patient on the same date of service. 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.
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.
You can learn more about the nuances of critical care coding for more than one provider, here.