Reporting Critical Care Services
Joette Derricks, CPC, CHC, CMPE, CSSGB
Vice President of Regulatory Affairs & Research, ABC
Anesthesiologists are uniquely qualified to coordinate the care of patients in the intensive care unit because of their extensive training in clinical physiology/pharmacology and resuscitation. Some anesthesiologists pursue advanced fellowship training to subspecialize in critical care medicine in both adult and pediatric hospitals. In the intensive care unit, they direct the complete medical care for the sickest patients. The role of the anesthesiologist in this setting includes the provision of medical assessment and diagnosis, respiratory and cardiovascular support and infection control. Clinical competence and expertise in meeting the needs of a critically ill or injured patient unfortunately does not automatically transfer to payer’s documentation and coding requirements. The following article reviews the critical care services documentation, coding and billing guidelines.
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The American Medical Association’s Current Procedural Terminology® (CPT) Codebook defines critical care as the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient. A critical illness or injury “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition”.
Critical care involves high complexity decision making to assess, manipulate and support vital system functions(s) to treat single or multiple vital organ failure and/or the prevention of further life threatening deterioration in a patient’s condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic and/or respiratory failure.
Delivering critical care in a moment of crisis, or upon being called to the patient’s bedside emergently, is not the only requirement for providing critical care service. Treatment and management of a patient’s condition in threatening imminent deterioration, while not necessarily emergent, is also required.
The presence of a patient in an Intensive Care Unit (ICU) or Critical Care Unit (CCU), or the patient’s use of a ventilator, is not sufficient to warrant billing critical care services. The service must be medically necessary and meet the definition of critical care. Medically reasonable and necessary services that do not meet all the criteria to report critical care should be reported with the appropriate evaluation and management code (e.g., CPT codes 99231-99233).
Since critical care is a time-based service, the physician’s critical care note(s) must document the total time spent evaluating, managing and providing critical care services to a critically ill or injured patient. Critical care time may be continuous or intermittent in aggregated time increments. Time spent performing other, separately billable procedures/services cannot be used to support critical care time.
The time spent providing critical care services must be at the immediate bedside or elsewhere on the floor or unit as long as the physician is immediately available to the patient. Therefore, the physician cannot provide services to any other patient during the same period of time.
In the teaching environment, the teaching physician must be present for the entire period of time for which the claim is submitted. Time spent teaching may not be counted towards critical care time. Teaching physicians, in addition, cannot bill for time spent by the resident providing critical care services in their absence. Only time that the teaching physician spends with the patient, or that he or she and the resident spend together with the patient, can be counted toward critical care time. Provided that all requirements for critical care services are met, the teaching physician’s documentation may tie into the resident’s documentation. The teaching physician may refer to the resident’s documentation for specific patient history, physical findings and medical assessment. However, it is the teaching physician’s stand-alone documentation that determines whether a critical care service can be billed.
The teaching physician medical record documentation must provide information including the time the teaching physician spent providing critical care; that the patient was critically ill during the time the teaching physician saw the patient; what made the patient critically ill; and the nature of the treatment and management provided by the teaching physician.
The following is an example of acceptable teaching physician documentation:
Patient seen and examined with Dr. Resident. Reviewed and agree with his note and the plan of care we developed together. One hour of critical care time personally performed due to patient’s hemo-dynamic instability. Patient was resuscitated with 2 units of packed red blood cells. Additional studies were obtained to determine possible causes for patient’s instabilities.
In 2014, the CPT Codebook lists the following services as included in critical care services and provides that they should not be reported separately: the interpretation of cardiac output measurements (93561, 93562), chest x-rays (71010, 71015, 71020), blood draw for specimen (36415), blood gases and information data stored in computers (e.g., ECGs, blood pressures, hematologic data) (99090), gastric intubations (43752, 91105), pulse oximetry (94760, 94761, 94762), temporary transcutaneous pacing (92953), ventilator management (94002-94004, 94660, 94662), and vascular access procedures (36000, 36410, 36415, 36591, 36600).
Time involved performing procedures that are not bundled into critical care (i.e., billed and paid separately) may not be included and counted toward critical care time. The physician’s progress note(s) in the medical record should document that time involved in the performance of separately billable procedures was not counted toward critical care time. For example, an emergency intubation may be billed separately as 31500 if supported by the documentation and the time is excluded from critical care time if both are being reported. What services are and are not bundled into critical care change from time to time and physicians along with their billing staff should review the list each January.
Routine daily updates to family members are considered part of critical care services and not separately billable. However, time spent with family member or other surrogate decision makers may be counted toward critical care time when these criteria are met:
- The patient is unable or clinically incompetent to participate in giving a history and/or decision making and
- The discussion is necessary for determining treatment decisions.
A summary of any family discussion is to be documented within the medical record and should show that the patient was unable or incompetent to participate as well as the necessity for the discussion and any treatment decisions made.
Telephone calls to family members and/or surrogate decision makers may be counted provided that they meet the same criteria as described above. All other family discussions, no matter how lengthy, may not be counted towards critical care time.
Critical Care Services Codes
- Code 99291 (critical care, first hour) is used to report the services of a physician providing constant attention to a critically ill patient for a total of 30 to 74 minutes on a given day.
- Only one unit of code 99291 may be billed by a physician for a patient on a given date.
- If the total duration of critical care provided by the physician on a given day is less than 30 minutes, the appropriate evaluation and management code should be used. In the hospital setting, it is expected that the Level 3 subsequent hospital care code 99233 would most often be used.
- Code 99292 (critical care, each additional 30 minutes) is used to report the services of a physician providing constant attention to the critically ill patient for 16 to 30 minutes beyond the first 74 minutes of critical care on a given day.
- The following illustrates the correct reporting of critical care services:
Total Duration of Critical Care Code(s)
|Less than 30 minutes||99232 or 99233|
|30-74 minutes||99291 x 1|
|75-104 minutes||99291 x 1 and 99292 x 1|
|105-134 minutes||99291 x 1 and 99292 x 2|
|135-164 minutes||99291 x 1 and 99292 x 3|
Important Coding Requirements
- 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/injured patient. Documentation in the patient’s medical record must support the specific time that the physician was present at bedside or engaged in work directly related to the individual patient.
- Physicians assigned to a critical care unit (hospitalist/intensivist) may not report critical care based on a “per shift” basis.
- Claims for seemingly improbable amounts of critical care on the same date are subjected to review to determine if the physician has filed a false claim.
- Services cannot be reported as a split/shared service when performed by a physician and a nonphysician provider (NPP) in the same or another group practice.
- Physicians in the same group practice, with the same specialty, may not report 99291 for the same patient on the same calendar date. 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 or qualified NPP on the same calendar date.
- CPT Code 99292 (subsequent critical care visits) are for additional critical care time performed on the same calendar date. The service may represent aggregate time met by a single physician or physicians in the same group practice and in 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.
- Concurrent care by more than one physician representing different specialties is payable if the services meet critical care requirements, (i.e., must be medically necessary and non-duplicative time and services.)
- Hospital emergency department services are not payable for the same date as critical care services when provided by the same physician or physicians of the same specialty.
- Critical care services will not be paid on the same calendar date that a physician reports an unbundled preoperative procedure with a global surgical period, unless the critical care is billed with modifier -25 to indicate that a significant, separately identifiable E/M service was performed. An ICD-9-CM code in the range 800.0 through 959.9 (except 930-939), which clearly indicates that the critical care was unrelated to the surgery, is acceptable documentation.
- Postoperative critical care may be paid in addition to a global fee if the patient is critically ill and requires the constant attendance of the physician, and the critical care is unrelated to the specific anatomic injury or general surgical procedure performed. In order for these services to be paid, two reporting requirements must be met. Codes 99291/99292 and modifier “-24” (Unrelated evaluation and management service by the same physician during a postoperative period) must be used, and documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted. An ICD-9-CM code in the range 800.0 through 959.9 (except 930-939), which clearly indicates that the critical care was unrelated to the surgery, is acceptable documentation.
- AMA/CPT 2014 Critical Care Services
- http://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf, Section 30.6.12
- http://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf, section 100, Teaching Physician
Joette Derricks, CPC, CHC, CMPE, CSSGB serves as Vice President of Regulatory Affairs and Research for ABC. She has 30+ years of healthcare financial management and business experience. She is a member of MGMA, HCCA, AAPC and other associations and a regular speaker at practice management conferences. She can be reached at Joette.Derricks@AnesthesiaLLC.com.