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Inpatient visits and critical care

  1. #1
    Default Inpatient visits and critical care
    Medical Coding Books
    I need verification that I am interpreting the following medicare transmittal correctly.

    A. Hospital Visit and Critical Care on Same Day
    When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service. Hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.

    During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 – 99233.

    Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.

    Physicians and qualified nonphysician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims. The retained documentation shall support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for the same patient on the same calendar date as other E/M services.

    My question concerns the second paragraph. I am reading that if a provider treats a patient for 45 minutes and only 30 minutes is critical care, the provider may report an inpt CPT code for the other 15 minutes.

    I apreciate any and all opinions.

    Susan Ayres, CPC

  2. #2
    Milwaukee WI
    Default You need both Para 1 and Para 2
    I think you can't just take paragraph 2 by itself. I think you need to take into consideration what paragraph 1 is saying.

    Per P1 .. .if the patient starts out NOT requiring critical care and later on the same date of service does require critical care you can code both the E/M (new or subsequent) w/ a -25 mod and the critical care.

    Then, per P2 ... a patient who is still being managed by Critical Care, but whose cares don't meet that definition, should have services coded as subsequent hospital visit. (e.g. patient is still in the ICU, but sufficiently stable that care provided no longer meets definition of critical care).

    So, no. If you spend 45 minutes w/ patient and only 30 minutes of it is critical care, you can't add a 99231-99233 code to cover the "extra" 15 minutes. You would code only the critical care ... or you'd code only the subsequent visit.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Flower City
    Only the actual time of the critical care service being rendered is proper to bill for.

    Just any FYI on the subject of billing and E/M and Critical Care on the same date:

    Critical care services and E/M service billing on the same date is a rarity and most likely you would need to supply the insurance carrier with documentation to support the reason and the medical necessity for billing both service on the same date for the same patient by the same provider.

    The only circumstance that I am aware of were billing an E/M and Critical Care on the same date would be for example:

    Provider sees the patient on the floor - documents and bills a 99232. Sometime later on the same date the patient "crashes" and the provider renders "critical care" services at that time when the patient is in imminent danger. The provider documents the total time, medical necessity,details of his/her intervention for critical care services and codes 99291, 99292 etc based on the total time requirements per code.
    Marianne Wink, RHIT, CPC, ACS-EM

  4. #4
    Thank you for both insights. I have audited the hospitalist H&P and believe he performed the services at the same time, but I wanted to feel confident that I read the documentation guideline correctly before I explained that he could not charge for both if performed at the same session.
    Susan Ayres, CPC

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