Part B Insider (Multispecialty) Coding Alert

Published on Wed Aug 27, 2003 PDF

Life-threatening situations, tough decisions - and bundling edits - all come with critical care. When patient's lives are threatened, Medicare expects your doctor to do everything in his power to save the day, without billing for anything separately.

But you can legitimately bill for some things on the same day as an episode of critical care, says Michael Miscoe, president of Practice Masters Inc. in Central City, Pa.

You can only bill for E/M services on the same day as critical care (99291) if the services and diagnoses are completely separate, says Roger Holland, president of Utilization PRO in Tyler, Texas. Say you have an inpatient visit with a patient in the morning, with high E/M levels. Then in the afternoon, the patient has a cardiac arrest and you're called for a "code." You can bill for both the E/M and the critical care using modifier -25.

You can override edits for 99291 with 36000, 36410, 36511, 36512, 36513, 36514, 36515, 36516, 36600, 38206, 71010, 71015, 71020, 91105, 92953, 93040, 93041, 93042, 93561, 93562, 97001, 97002, 97003, 97004, G0001, 61793, 77776, 90845, 90853, 90857, 90865, 90880, G0101, G0104, G0105, G0106, G0120, G0121, G0242, G0243, P3000, P3001 and Q0091 using a modifier, Miscoe says.

Be Careful of Time-Based Billing

You can bill for extra critical care services based on time spent, but only if the physician gave the patient his undivided attention during that time, Miscoe says. "You can't provide services to more than one patient at a time" during critical care time. For the first half-hour after 74 minutes of critical care, you can bill 99292 in addition to 99291. If the physician spends more than 104 minutes with the patient, you can bill two units of 99292 in addition to 99291.

If a patient is unable to communicate, then conferences with family members count toward critical care time, Miscoe says. But "the discussion has to be absolutely necessary for treatment options under consideration that day, and has to be documented in the progress notes." Telephone calls to family members count just as much as face-to-face conferences, he adds.