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Thread: 99291

  1. #1

    Default 99291

    Chapter 12, section 30.6.12 I of the Medicare Claims Processing Manual 100-04 has the following statement regarding critical care services:
    CPT Code 99291
    The initial critical care time, billed as CPT code 99291, must be met by a single physician or qualified NPP. This may be performed in a single period of time or be cumulative by the same physician on the same calendar date. A history or physical exam performed by one group partner for another group partner in order for the second group partner to make a medical decision would not represent critical care services.
    CPT Code 99292
    Subsequent critical care visits performed on the same calendar date are reported using CPT code 99292. 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. The aggregated critical care visits must be medically necessary and each aggregated visit must meet the definition of critical care in order to combine the times.
    Physicians in the same group practice who have the same specialty may not each report CPT initial critical care code 99291 for critical care services to the same patient on the same calendar date. Medicare payment policy states that physicians in the same group practice who are in the same specialty must bill and be paid as though each were the single physician. (Refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.)
    My question is this: Can 2 providers with the same specialty in the same group practice combine their time to report one 99291 under one of the doctors NPI's?

  2. #2
    Join Date
    Apr 2007
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    Milwaukee WI
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    Default Same specialty

    Two physicians in the same practice with the same specialty are considered ONE provider by most payers (CMS definitely).

    Combine the times and report under one NPI. Your practice should have a protocol in place so you are consistent with this ... always bill under the FIRST provider who saw the patient, or always bill under the LAST provider who saw the patient. We always bill under the first provider.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Join Date
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    1,716

    Default It may depend on your carrier

    Per WPS Medicare, no you can not combine 2 providers time/documentation to meet 99291. The initial 30 minutes must be met by 1 provider, then you can add the others time together and bill for it.

    So if Dr. A documents 25 minutes and Dr. B documents 25 minutes and Dr. C documents 25 minutes, you can't bill critical care at all because nobody met the 30 minute minimum by themselves.

    http://www.wpsmedicare.com/part_b/po...es/phys022.pdf

    "CPT Code 99291
    The initial critical care time, billed as CPT code 99291, must be met by a single physician or
    qualified NPP. This may be performed in a single period of time or be cumulative by the same
    physician on the same calendar date. A history or physical exam performed by one group partner for
    another group partner in order for the second group partner to make a medical decision would not
    represent critical care services."

    Laura, CPC, CPMA, CEMC

  4. #4
    Join Date
    Apr 2007
    Location
    Milwaukee WI
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    4,453

    Default My bad

    Laura is correct ... In my response, I was assuming that provider # 1 had already met the 30minutes threshhold for 99291 on his/her own.

    F Tessa Bartels, CPC, CEMC

  5. #5

    Default

    Thank you for your responses.

    The CMS Claims Processing Manual seems rather contratictory in regard to this, I believe. They do make it very clear that providers of the same specialty within the same practice should bill and be reimbursed as though they a single physician. I totally get that and have no qualms about billing as such EXCEPT for CPT 99291.

    Some of my peers feel that the physicians in group practices language alone should be clear enough to support 2 physicians aggregating their time in order to report 99291.

    I disagree. I don't know why they would carve out other than that specific to this code if they didn't intend it to be cumulative or continual time of at least 30 minutes by one single person and intend it to be separate from their general physicians in group practices guidelines.

    I suppose it comes down to how the MAC interprets it. We happen to fall under Cahaba and all I can find on their website is that they follow CMS.

    I feel like I am walking in circles. If anyone can point me to anything more specific regarding what Cahaba recommends I would really appreciate it.

    Thank you for your time.

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