Medicare Compliance & Reimbursement

Ensure you’re following the rules by reviewing these 11 citations and quotes from the Centers for Medicare & Medicaid Services (CMS) and MACs on critical care time documentation, provided by Todd Thomas, CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK.

1. CMS Claims Manual

30.6.12 - Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292)

E. Critical Care Services and Physician Time

Critical care is a time-based service, and for each date and encounter entry, the physician’s progress note(s) shall document the total time that critical care services were provided. Resource: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf.

2. CMS Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.12:

Critical care is a time-based service, and for each date and encounter entry, the physician’s progress note(s) shall document the total time that critical care services were provided. The duration of critical care services to be reported 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 long as the physician is immediately available to the patient. For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

The CPT^® critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT^® code 99291 is a prerequisite to reporting CPT^® code 99292. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician.

3. E/M Services Billing Guide

March 2011

NHIC, Corp.

Critical care is a time-based service, and for each date and encounter entry, the physician’s progress note(s) shall document the total time that critical care services were provided. Resource: www.medicarenhic.com/providers/pubs/Evaluation and Management Services Billing Guide.pdf.

4. Time-Based Services J1 Medicare Part B

Palmetto GBA February 2012

Critical Care Services Provider’s Time:

Total time must be documented for each date and encounter entry. Resource:  www.palmettogba.com/Palmetto/Providers.Nsf/files/Time_Based_CPT_Codes_020512.pdf/$File/Time_Based_CPT_Codes_020512.pdf.

5. Novitas: Evaluation & Management: Service-Specific Coding Instructions

Medical Review Guidelines Regarding “Full Attention” and Physician Time in Critical Care Services

Since critical care is a time-based code, the physician’s progress note must contain documentation of the total time involved providing critical care services.

6. Jurisdiction 12 Medicare Part B Presents: Critical Care

January 25, 2013

Critical Care Documentation Requirements

Time based codes require documentation of total time spent providing critical care services Medical necessity must be evident. Resource: www.novitas-solutions.com/calendar/partb/pdf/tc-handout-012513-j12.pdf.

7. WPS — Medicare Documentation Q&As

Q5. Can I use a check box indicating 30-74 minutes instead of saying I spent 51 minutes in critical care? In addition, the doctor was in and out of critical care for the patient all day. Is it ok at the end of the day to document “45 minutes today?”

A5. Document the total time spent each time you visit the patient. CMS IOM, Section 30.6.12.E states, “Critical care is a time-based service, and for each date and encounter entry, the physician’s progress note(s) shall document the total time that critical care services were provided.” Resource: www.wpsmedicare.com/j8macpartb/resources/provider_types/evalmngmntqa.shtml.

8. WPS — Documenting Time in Medical Records

Critical Care Services

Critical care is a time- based service, and for each date and encounter entry, the physician’s progress note(s) shall document the total time that critical care services were provided. The duration of critical care services to be reported 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 long as the physician is immediately available to the patient. Resource: www.wpsmedicare.com/j8macpartb/departments/cert/2010_0329_time.shtml.

9. Noridian Administrative Services Critical Care Billing and Coding Workshop Q&A

Q9. Is it necessary to document start and stop times or just the total amount of time spent providing critical care?

A9. The physician must document the total time spent providing critical care for the patient. Resource: www.noridianmedicare.com/partb/train/workshops/qa/critical_care_billing_and_coding.html

10. Critical Care Billing and Coding — Presented by:
NAS Part B

Critical Care Documentation

·         Accurate reflection of the critical nature

·         Complexity of medical decision making

·         Aggregation of time spent by the billing provider if applicable

·         Patient assessment

·         Family discussions — substance of discussion

·         Total time — Key Component

Resource: www.noridianmedicare.com/partb/train/workshops/docs/materials_092612_critical_care_billing_and_coding.pdf.

11. Noridian Administrative Services Evaluation and Management Billing, Coding, and CERT Workshop Q&As

Q8. In addition to time and the documenting of time, what other documentation is required when coding critical care? Does the provider need to document briefly or extensively as to what type of care he/she provided?

A8. The physician needs to extensively document what they construed as critical care for the patient. The critical care section of the CPT^® outlines the context of what is needed in order to qualify for critical care.