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Thread: Critical Care Coding

  1. #1

    Default Critical Care Coding

    AAPC: Back to School
    Medicare denied this claim (the 99292) they do not want two different doctors on a claim. Patient seen in the E.R. Dr M sees patient does 35 mins of critical care, Dr J. takes over the shift and does another 40 minutes of critical care. Dr M was coded 99291 and Dr. J was coded 99292 Medicare denied claim stating they do not want two different doctors on a claim. Does anyone know the correct way to bill this claim (25 modifier as applied on the 99291 that did not make a difference).. Thanks in advance Cathy Although they are in the same practice can critical care time be billed under the last physicians name??
    Last edited by cathyflower; 05-24-2010 at 07:19 PM. Reason: spelling

  2. #2


    CPT Guidelines state only one Physician can code the CC episode if the physicians are both with the same group. So you have to combine the 35 + 40 minutes and code/bill for 1 hour of CC time with 99291 and 99292 for the extra 15 minutes.

    Ask them both to decide who wants to take this episode for coding and billing. For me, I would probably code/bill under the physician that had the most time.

    Is that all they did? Remember CCare is coded in addition to any other E&M service that same day. Meaning if your Physician was called to the ER to eval and admit the patient and the patient crashed, he can still code for his InPt initial 99221-99223 plus the CCare episode
    Last edited by sbicknell; 05-25-2010 at 05:26 PM.

  3. #3

    Default critical care time

    both doctors are emergency room doctors employed by the same group..this situation was a shift change. They get paid based on performance that is why it was billed separate. I thought you could bill the first M.D 99292 and the second 99291? Medicare does not like it to be billed that way..both doctors of course would want their pay..
    Last edited by cathyflower; 05-26-2010 at 08:24 PM. Reason: typo

  4. #4


    I would see a big problem coding 99291 for each. You only have 75 minutes of time.

    For simplicity, let say the 99291 is worth $200 and the 99292 is worth $100. Billing the way you have suggested would get you $400 when you are really only due $300

    I guess this is where counting workload butts heads with coding. The following is from CMS:

    For Medicare Part B physician services paid under the physician fee schedule, critical care is not a service that is paid on a “shift” basis or a “per day” basis. Documentation may be requested for any claim to determine medical necessity. Examples of critical care billing that may require further review could include: claims from several physicians submitting multiple units of critical care for a single patient; and submitting claims for more than 12 hours of critical care time by a physician for one or more patients on the same given calendar date. Physicians assigned to a critical care unit (e.g., hospitalist, intensivist, etc.) may not report critical care for patients based on a “per shift” basis.
    Last edited by sbicknell; 05-25-2010 at 09:12 PM.

  5. #5


    I see this as one patient encounter in the ED. In the ED, when a different physician comes in because of a shift change, we place the bill under one physician, usually the last physician to see the patient.

    For Critical Care services in the ICU, we have more than one physician per day billing Critical Care. The initial critical care for the day begins with the 99291, if another physician continues to perform critical care later in the day, they continue with the 99292 code. The next day would start over.

    Diana, CPC
    Physician Auditor

  6. #6
    Join Date
    Apr 2007
    Hartford, CT


    medicare won't pay the 99292, it is appropriate to bill, they typically never reimburse. that is what i have always been told.
    Pat A. Trautner, CCS/CPC/CEDC/CHONC

  7. #7

    Default Critical care

    Thanks everyone,, sbkicknell, i meant to type 99291 for the first MD and 99292 for the second doctor. Trying to make sure i understand this correctly, If credit is giving to the second doctor that took over the shift, do you count the minutes for critical care that the first MD performed or only the second MD? Ex MD #1 performed 35 minutes # 2 MD 40 minutes bill 99291 and 99292 under the second doctor or only 35 minutes under the second doctor? 99292 says 75-104 minutes 99291 plus 99292 this would be 75 minutes combined ? thanks again for all the help. Sorry so confusing. Cathy
    Last edited by cathyflower; 05-26-2010 at 08:23 PM. Reason: spelling

  8. #8


    According to the guideline I pasted, you can not separately bill the CC time just cause of a shift change

    For Medicare Part B physician services paid under the physician fee schedule, critical care is not a service that is paid on a “shift” basis or a “per day” basis. .......... Physicians assigned to a critical care unit (e.g., hospitalist, intensivist, etc.) may not report critical care for patients based on a “per shift” basis.

    Think of it this way. The patient didn't make an ED appt with a specific Doc. The ER Docs are there as an "assigned team" to provide care for the ED patient. The ED Docs are to code/bill as one Doc regardless of who "on the team" has treated the patient. Make sense?

    So, combine the CC time into one billable session and for me, I would bill all the CC time under the Doc that ended the session.

    You said you had 35 min and then an additional 40 min for a total of 75 min. The CPT 99291 is for the first 60 minutes, so code 99291. That leaves 15 minutes still to bill for. The 99292 is defined as an additonal 30 minutes and you must meet that code 1/2 (or 15 minutes) in order to code it. And you do. So code the 99292 for the left-over 15 minutes

    The "1/2 way rule" is why 99291 goes from 30 to 74 minutes. At 74 minutes you are 1 minute short from meeting the 1/2 way rule. So if your total time would have been 30 + 40 for a total of 70, then you would have only been able to code 99291. Make sense?

    And you can't code/bill a 99292 without first coding the 99291. The 99292 is an "add-on code" which is why it is marked with the little "+" sign in the code book. And you must have at least 30 minutes of CC time in order to code the 99291

    As far as Doc #1 complaining he didn't get any coding (workload/payment) for his time treating the patient....that is a separate issue from correct coding. The ED Docs would need to take that up the chain to be reviewed to see how often this scenario comes up and much it affects each ED Doc. Not your issue
    Last edited by sbicknell; 05-26-2010 at 09:07 PM.

  9. #9

    Default Critical care coding


    I took this article from the site - http://www.acep.org/Content.aspx?id=30466.

    The content is that -

    1. Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient

    2. In case of two physicians -The service may represent aggregate time met by a single physician or physicians in the same group practice with the same medical specialty in order to meet the duration of minutes required for CPT code 99292

    So in the scenario you mentioned is that Doctor A rendered CC service for 35 minutes and Doctor B for 40 minutes, if combined we have total of 75 mts. The initial CC service is for 30-74mts and we have only 1minute in addition.

    Medicare would require atleast 15minutes in addition to the initial service to bill for 99292 and we can only bill with 99291. We can check with both the providers who need to be benefitted, or based on the work up and extensive evaluation we can decide on either one of the Physicians to take the credit.

    Hope this clear your query.

    Correct me if i am confused.

    Thank You,

    Purnima S, CPC

  10. #10

    Default Critical care

    hI, on response says you can bill 99292 starting with 75 mins the other response said you need at least 15 mins pass the 75 in order to bill the 99292 Am I reading that correct? thanks Cathy

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