Question Critical Care Documentation

Crisgo88

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I have something completely different and can't find guidelines. A NP sees and performs Critical Care services, documentation is completed. Then the physician comes by and sees the patient and adds the following attestation to the NP's note.
"I examined the patient at the bedside with the critical care team, including the person that wrote this note. We reviewed all laboratory data, radiologic studies, and discussed the past and future treatment plan. Additionally, I reviewed the findings and assessment/plan outlines in this note and agree, with any exceptions and/or additions noted. I personally spent >30 minutes guiding care."
#1 I checked with the NP and she was not in the room with the physician
#2 The physician bill 99291 and the NP bills 99292 for time over 74 minutes even though she saw the patient prior to the physician. OR 99291 is only billed under the physician if he claims 35 minutes and the NP claims 35 minutes.
#3 I don't know who comprises the Critical Care Team
#4 The same thing is done on subsequent visits.
#5 There is a resident present with the physician on the majority of the encounters. I know the time spent teaching the resident can't be included.
#6 On occasion, there is an additional statement by the physician that states why the patient requires Critical Care and reiterates continuing specific orders.
#7 I'm concerned about the "guiding care" statement instead of "Providing Critical Care".

Can anyone lead me to guidelines that state each provider must document their own progress note for Critical Care or any other issues I'm not comfortable with?
 

Mayzoo

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One or the other (but not both) can bill for Critical Care: https://www.the-hospitalist.org/hospitalist/article/125598/health-policy/how-avoid-medicare-denials-critical-care-billing

"When a physician and a nurse practitioner (NP) see a patient on the same calendar day, critical-care reporting is handled differently. A single unit of critical-care time cannot be split or shared between a physician and a qualified NP. One individual must meet the entire time requirement of the reported service code. "


Also: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2997CP.pdf


AND: https://www.aapc.com/discuss/threads/critical-care-involving-md-and-np.110573/

"As noted above, assuming the NP and MD are employed by the same entity you would bill the MD as follow on staff care. You would bill a 99291 under the NPs NPI for the first hour. Then you would bill a 99292 under the MDs NPI for the additional 30 minutes. There is a lot of confusion by Medicare carriers on this since the two providers are paid at different rates. A few carriers are not allowing an APP (PA or NP) and a physician to bill on the same patient. However, our carrier Cahaba is allowing the billing. For more information please see:
http://www.sccm.org/Communications/Critical-Connections/Archives/Pages/Billing-Basics-Billing-for-Critical-Care.aspx
also specifically on APP billing make sure you read the additional notes:
http://www.sccm.org/SiteCollectionDocuments/Carpenter Sidebar.pdf "



Based on what you wrote, if critical care was medically necessary, I would bill the total critical care time under the NP's NPI number--BUT I am still new to coding.
 
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