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Yale Medical Group
Medical Billing Compliance Department
CRITICAL CARE SERVICES
FREQUENTLY ASKED QUESTIONS
Please see the current CPT manual regarding separate guidelines for neonatal & pediatric critical care services
(CPT codes 99466-99469, 99471-99472, 99475-99480, 99184 & 99485-99486)
1. What services are bundled with the Critical Care Codes?
The following procedures/services are included in reporting critical care when performed on the day a physician bills for critical care and therefore should not be coded separately. The time spent performing these procedures should be included in the physicians’ total calculation of time when reporting critical care and should not be subtracted from reported critical care time.
CPT CODES DESCRIPTOR
36000 Introduction of needle or intracatheter, venous
36410
Venipuncture, age 3 years or older necessitating physician’s skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)
36415 Collection of venous blood by venipuncture
36591 Collection of blood specimen from a completely implantable venous access device
36600 Arterial puncture, withdrawal of blood for diagnosis
43752 Naso- or oro-gastric tube placement, requiring physician’s skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report)
43753 Gastric intubation and aspiration(s) therapeutic, necessitating physician’s skill (e.g. for gastrointestinal hemorrhage), including lavage if performed
71010, 71015, 71020 Chest X-rays (see CPT for specific definitions
92953 Temporary transcutaneous pacing
93561, 93562 Interpretation of cardiac output measurements (See CPT for specific code definitions)
94002-94004, 94660, 94662 Ventilator management (See CPT for specific code definitions) 94760, 94761, 94762 Pulse Oximetry (See CPT for specific code definitions)
99090 Analysis of clinical data stored in computers (e.g. ECGs, blood pressures, hematologic data)
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2. What professional services are included when Critical Care Time is calculated?
Thetime spent with the critically ill or injured patientis counted if the physician devotes his or herfull attention to the patient and, therefore, cannot provide services to any other patients during the same period of time.
Also counted is the time the attendingspent engaged in work directly related to the individual patient’s care, whether that time is spent at the immediate bedside or elsewhere on the floor or unit (reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff or documenting critical care in the medical record).
When the patient is unable or clinically incompetent to participate in discussions, the attendings’ time spent on the floor or unit with family members or surrogate decision-makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or
limitations(s) of treatment, provided that the conversation bears directly on the management of the patient, can be counted. The Center for Medicare & Medicaid Services (CMS) requires the
following documentation criteria be included in the record in order to include this time in critical care services:
o The patient was unable or incompetent to participate in giving a history and/or making decisions as appropriate.
o The necessity of the discussion (e.g., “no other source was available to obtain a history” or because the patient was deteriorating so rapidly I needed to discuss treatment options with family immediately”)
o The treatment decisions for which the discussion was needed o The substance of the discussion as related to the treatment decision
Telephone calls to family members and or surrogate decision-makers may be counted towards critical care time, but only if they meet the same criteria outlined above. (Centers for Medicare and Medicaid Services (CMS) Transmittal 1548)
3. What professional services cannot be included when calculating Critical Care
Time?
Time spent in activities that occur outside of the unit or off the floor may not be reported since the physician is not immediately available to the patient.
Examples of services that cannot be included when calculating critical care time:
o Patient is transported to another area of the hospital for an MRI and the physician does not accompany the patient
o Telephone calls, whether taken at home, in the office, or elsewhere in the hospital o Time spent in activities that do not directly contribute to the treatment of the patient
o Family discussions, no matter how lengthy, such as periodic updates, emotional support of the family, and answering questions regarding the patient’s condition (only questions related to decision-making regarding treatment as described above, may be counted toward critical care)
Other services not listed above, should be reported separately. Time involved in performing procedures that are not bundled into critical care (coded and billed separately) should not be included and reported as critical care time.
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4. How do I calculate Critical Care Time?
The critical care evaluation & management (E&M) service is a timed based service and does not have the same documentation requirements for history, exam, and medical decision making as the other E/M codes.
CPT code 99291 is used to report the first 30–74 minutes of critical care rendered to a given patient on a given date of service. It should be used only once per date even if the time spent by the
physician is not continuous on that date. It may be used to report the accumulation of smaller blocks of time totaling 30-74 minutes that given date.
CPT code 99292 is an “add-on code” and may only be used in conjunction with 99291. It is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes. See Critical Care Table on fact sheet, which illustrates the correct reporting of critical care services.
Time is cumulative for any given service date. For example, a physician sees a patient in the ED at 1 a.m. and spends 35 minutes of critical care time with the patient. The patient is admitted to ICU, and two hours later the same physician is called to the ICU and spends another 20 minutes of critical care time with the patient. Only assign a total of 55 minutes of critical care time for that date of service (i.e., 99291 one time only). If the physician were to be called a third time to see the patient on that same date of service and was to spend another 25 minutes of critical care time with the patient for a total of 80 minutes, then, in addition to 99291 code, 99292 should also be coded.
The physician must document in the record the amount of time spent providing critical care services. This time cannot be inferred from the physician’s record. If the time is not stated, the physician should be contacted and asked what CPT code is appropriate for the service.
When coding critical care services, the time required to perform separately coded procedures and services should be excluded from the reported critical care time. CMS states that this policy applies to any procedure with a 0-, 10-, or 90-day global period including CPR (CPT code 92950). These procedures can be coded separately and in addition to the critical care code. Intubation and CPR are examples of a procedure, and a service that, when performed during critical care, should be coded separately and the time involved performing these services should not be included in the total critical care time reported.
When determining the amount of critical care time to code, include the time documented providing critical care services, and then subtract the applicable time spent performing separately coded procedures or services and then assign the appropriate critical care code(s) based on the remaining total time.
The physician’s progress note must document that time involved in the performance of separately billable procedures was not counted toward critical care time.
When procedures are assigned in addition to critical care codes, a modifier -25 should be added to the critical care E&M service(s). If modifier -25 is assigned to 99291; it must also be added to 99292, if appropriate.
The following table is presented as a guideline only for considering the minimal amount of time it would take to perform the listed procedure. This list does not include every possible procedure that might be coded and the documentation should always be considered when evaluating
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Subtracting Time for Separately Reportable/Non-Bundled
Procedures from Critical Care
_
CPT CODES DESCRIPTION MINIMAL AMOUNT OF TIME TO
PERFORM PROCEDURE
31500 Endotracheal intubation 1 minute 31603 Transtracheal tracheostomy, emergency procedure 1 minute 31605 Transtracheal tracheostomy, cricothyroid membrane 1 minute
32556, 32551 Thoracentesis with insertion of catheter (32556). Tube
thoracostomy
5 minutes
33010 Pericardiocentesis 3 minutes
33210 Temporary transvenous pacing 5 minutes
36680 Placement of needle for
intraosseous infusion
2 minutes
92950 Cardiopulmonary resuscitation Total time compressions are being performed or total time between CPR start and CPR stop time documented in the record.
93010 Routine ECG with at least 12 leads; interpretation and report only
1 minute
5. Where can you provide Critical Care services?
Critical care may be assigned for professional services delivered in any area as long as all the criteria are met. Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility. Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes (e.g. subsequent hospital visit codes 99231 – 99233, or inpatient consultation codes 99251 – 99255), depending on the level of service provided.
Examples that do not satisfy Medicare’s criteria for critical care payment include:
o Patients admitted to a critical care unit because no other hospital beds were available
o Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs
o Patients admitted to a critical care unit because hospital rules require certain treatments (e.g. insulin drips) to be administered in the critical care unit
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6. Can an E&M (evaluation & management) service be provided on the same day
as Critical Care by the same provider?
Critical care may, in rare circumstances, be assigned with another E&M code on the same day.
When E&M services are furnished by a provider earlier on a date at which time the patient did not require critical care, and the same provider (or providers in the same group of the same specialty) subsequently renders critical care, both the critical care and the previous E&M service may be paid on the same date of service.
When critical care services are required upon the patient’s presentation to the ED, then only critical care codes (99291-99292) may be reported. An ED visit code (99281-99285) may not also be reported. (CMS Medicare Claims Processing Manual, Chapter 12, Section 30.6.12, H )
o Example: A 75-year-old female arrives in the ED after a motor vehicle accident, has multiple rib fractures and is experiencing respiratory distress. The ED physician provides 35 minutes of critical care services. A trauma specialist is called to the ED, who then assumes responsibility for the patient, and admits the patient to the SICU. The patient later suffers acute respiratory failure, and the trauma specialist provides 40 minutes of critical care service. In this example, as long as the critical care services are not duplicative of each other, and not provided during the same instance, and supported by separate documentation, the ED physician may report critical care service (99291), and the trauma specialist may report both: E&M-Initial hospital care visit (99223-AI) and Critical Care service (99291).
Note: The documentation should support the break in services, and the change in the patient’s condition. If there is no break in services, bill only the critical care services.
[Source: Medicare, Wisconsin Physician Services, Facility Services (Q&As), 20 May 2014]
7. Can two physicians provide and bill Critical Care on the same date of service?
If physicians are of different groups and/or specialties, they may each provide and bill critical careservices to the same patient on a given date, if the services are medically necessary, the condition each physician is treating and the care rendered meet the definition of critical care, and the services are not duplicative (see example above).
(Centers for Medicare and Medicaid Services (CMS) Transmittal 1548 and Medicare claims processing manual, Pub. 100-04, chpt 12, 30.6)
If two physicians of the same specialty, in the same group, provide critical care to the same patient on the same date, they must bill as if they were one physician, combining their time and reporting 99291 and (if applicable) the appropriate number of units of 99292.
The initial critical care time billed as CPT code 99291 must be met by a single physician or qualified APP.
o Example critical care billing for two providers of the same specialty on the same day:
Two pulmonary specialists, who share a group practice, each provide critical care services (at different times during the same day) to a patient who has multiple organ dysfunction (including cerebral hematoma, flail chest and pulmonary contusion), is comatose, and has been in the intensive care unit for 4 days following a motor vehicle accident. Both physicians may report
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medically necessary critical care services provided at the different time periods. One physician would report CPT code 99291 for the initial visit and the second, as part of the same group practice, would report CPT code 99292 on the same calendar date if the appropriate time requirements are met.
o The CPT code 99291 (critical care, first hour) is used to report the services of a physician providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date. Only one unit of CPT code 99291 may be billed by a physician for a patient on a given date. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician and would not each report CPT 99291on the same date of service.
o 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.
o Example critical care billing for multiple providers of the same specialty on the same day: Three pulmonary specialists, who share a group practice, each provide critical care services (at different times during the same day) to a patient who has multiple organ dysfunction (including cerebral hematoma, flail chest and pulmonary contusion. All physicians may report medically necessary critical care services provided at the different time periods. The first physician would report CPT code 99291 for the initial 35 minutes of critical care service. The second, as part of the same group practice, would report CPT code 99292 X 1 after providing 60 additional minutes (25 mins added to initial 35 mins = 1st hour of CC) of critical care services on the same calendar date, and the third physician, as part of the same group practice, would report CPT code 99292 X 2 after providing an additional 50 minutes on the same calendar day.
If a physician or qualified APP within a group provides “staff coverage” or “follow-up” for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified APP), the subsequent visits by the “covering” physician or qualified APP in the group shall be billed using CPT critical care add-on code 99292. The appropriate individual NPI number shall be reported on the claim. The services will be paid at the specific physician fee schedule rate for the individual clinician (physician or qualified APP) billing the service.
8. Can Critical Care services be provided and paid during preoperative and/or
postoperative period of procedures?
A surgeon can be reimbursed for critical care services in the post-op period if the critical care criteria are met. Modifiers -24 (unrelated evaluation and management service by the same
physician during a postoperative period) or -25 (significant, separately identifiable evaluation and management service by the same physician on the day of the procedure) are required. Clear documentation that the critical care was unrelated to the specific anatomic injury; or general surgical procedure performed; or was beyond the typical work of pre-or postoperative care associated with the procedure(s).
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9. Can Critical Care services be provided and paid during preoperative and/or
postoperative period of procedures in Trauma and Burn Cases?
Critical Care services provided during preoperative portion of the global period of procedure with 90-day global period in Trauma and Burn Cases can be paid in addition to a global fee. In addition to modifier 25, documentation that the critical care was unrelated to the specific anatomic injury or general procedure performed must be submitted. An ICD-9-CM diagnosis code in the range of 800.0 through 959.9 (except 930-939) that clearly indicates that the critical care was unrelated.
Critical Care services provided during postoperative period of procedure with global period in Trauma and Burn Cases can be paid with critical care in addition to a global fee if critical care criteria are met and the critical care is unrelated to the specific anatomic injury or general surgical procedure performed. The modifier -24 (unrelated E&M 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 must be submitted. An ICD-9-CM
diagnosis code in the range 800.0 through 959.9 (except 930-939) that clearly indicates that the critical care was unrelated to the surgery isacceptable documentation.
10. Can qualified Advanced Practice Providers (APP) provide Critical Care
services?
Critical care services may be provided by qualified APPs and reported for payment under the APP’s National Provider Identifier (NPI) when the services meet the definition and
requirements of critical care services. The provision of critical care services must be within the scope of practice and licensure requirements for the State in which the qualified APP practices and provides the service(s). Collaboration, physician supervision and billing requirements must also be met. A physician assistant shall meet the general physician supervision requirements.
(Centers for Medicare and Medicaid Services (CMS) Transmittal 1548)
11. Is a Split/Shared Service permitted under the Critical Care guidelines?
A split/shared E/M service performed by a physician and a qualified APP of the same grouppractice (or employed by the same employer) cannot be reported as a critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time. (Centers for Medicare and Medicaid Services (CMS) Transmittal 1548)
CMS guidelines indicate that physicians and APPs cannot combine time toward a single unit of critical care (e.g., 99291) but that they can bill individually for sequential units (e.g. 99291 or 99292(s). The 99291 service must be done by ONE entity, and each 99292 must be done by ONE entity, but the PA, MD, or others must EACH totally perform the unit of time he/she billed.
o Example: If 74 minutes of critical care is provided by MD#1, the MD#1 bills 99291 and is paid for 60 minutes of critical care time. If an APP then provides 30 minutes of critical care, he/she cannot count the 14 minutes left from the MD’s time. If MD#2 of the same specialty/group practice provides 30 minutes of additional critical care time, he/she can count the 14 minutes left over from MD #1.
