Critical care coding is a complex area within medical billing, requiring precision and a thorough understanding of guidelines to ensure accurate reimbursement. For professionals in automotive diagnostics who are expanding their knowledge into medical coding or for those already in healthcare seeking to refine their expertise, understanding the nuances of Aapc Critical Care Coding is essential. This article, tailored for the English-speaking market and optimized for SEO, delves into the critical aspects of coding critical care services, drawing insights from authoritative sources like the AAPC (American Academy of Professional Coders) and CMS (Centers for Medicare & Medicaid Services).
Defining Critical Care Services in 2024
The foundation of accurate AAPC critical care coding lies in a clear definition of what constitutes critical care. Mirroring CPT® (Current Procedural Terminology) guidelines, critical care is defined as the direct medical care provided by a physician or qualified healthcare professional (QHP) to a patient who is critically ill or injured. This condition is characterized by:
- Acute impairment of one or more vital organ systems.
- A significant probability of imminent or life-threatening deterioration in the patient’s condition.
- The necessity for high complexity decision-making to address single or multiple vital organ system failures and/or to prevent further life-threatening decline.
This definition, adopted by CMS, underscores the severity and urgency inherent in critical care services. It’s crucial to remember that only services meeting this stringent definition should be coded as critical care.
Who Can Report Critical Care Codes?
Both physicians and nonphysician practitioners (NPPs) who are qualified healthcare professionals (QHPs) can report critical care services. CMS defines a QHP as an individual deemed qualified through education, training, licensure (where applicable), and facility privileging (where relevant), operating within their defined scope of practice. This broadens the scope of who can bill for these services, emphasizing the qualifications of the individual providing the care rather than solely their professional title.
Navigating CPT® Codes 99291 and 99292 for Critical Care
The cornerstone of AAPC critical care coding is the correct application of CPT® codes 99291 and 99292. These codes are used to report the total duration of critical care time, whether continuous or aggregated, delivered by a physician or QHP on a given service date. It’s imperative to exclude time spent on separately reportable procedures or services when calculating critical care time.
Handling Continuous Care Across Dates:
When critical care extends beyond midnight into the next calendar day, the service is considered continuous. A crucial point from CPT® guidelines, reinforced by CMS, is that a continuous service does not initiate a new “first hour” at midnight. However, any interruption in service does create a new initial service. This distinction is vital for accurate time calculation and code assignment, especially for prolonged critical care cases.
Concurrent Critical Care by Different Specialties:
AAPC critical care coding allows for concurrent critical care services provided to the same patient on the same day by practitioners of different specialties. This is permissible regardless of group affiliation, provided each service independently meets the definition of critical care and is not duplicative. CMS recognizes that in complex cases, multiple specialists may be required to actively contribute to a patient’s critical care.
Concurrent Critical Care Within the Same Specialty or Group:
When multiple practitioners of the same specialty or within the same group provide concurrent critical care to a single patient on the same day, coding rules differ slightly. Code 99291 should be reported for the initial critical care provided by the first physician or NPP. Subsequent critical care provided by others in the same specialty or group is reported using 99292. Notably, time can be aggregated between practitioners in the same group to meet the minimum time threshold for 99291. This deviates from standard CPT® guidance and is specific to CMS billing rules.
Bundled Services in Critical Care
CPT® 2022 and subsequent updates have clarified which services are bundled into critical care and therefore not separately payable when furnished concurrently. These include:
- Interpretation of cardiac output measurements (93561, 93562)
- Chest X-rays (71045, 71046)
- Pulse oximetry (94760-94762)
- Blood gases and collection/interpretation of physiologic data (ECGs, blood pressures, hematologic data)
- Gastric intubation (43752, 43753)
- Temporary transcutaneous pacing (92953)
- Ventilator management (94002-94004, 94660, 94662)
- Vascular access procedures
Understanding this bundling is crucial for preventing claim denials and ensuring accurate AAPC critical care coding. Comprehensive documentation is essential to justify the critical care service and the necessity of any bundled procedures.
Split/Shared Critical Care Visits
A significant update in recent years is the allowance of split/shared billing for critical care services. For services on or after January 1, 2022, critical care can be billed as split/shared evaluation and management (E/M) services. The practitioner who performs the substantive portion (more than half of the cumulative total time) of the critical care can bill for the entire service. When practitioners jointly spend time with or discuss the patient, that time is counted only once. Modifier FS, Split (or shared) evaluation and management visit, is appended to claims for shared services between a physician and an NPP.
Update for 2023: CMS guidelines clarify that to bill split/shared critical care, CPT code 99291 is reported initially. If the cumulative critical care time reaches 104 minutes or more, then CPT code 99292 is reported for each additional 30 minutes increment.
Critical Care and E/M Services on the Same Day
AAPC critical care coding permits billing for both critical care and other Evaluation and Management (E/M) visits by the same practitioner, in the same specialty or group, on the same day under specific conditions. This is allowed if the practitioner documents that the hospital E/M service was provided when the patient did not require critical care, and that service was separate and distinctly identifiable from any critical care services provided later on the same day. Modifier 25, Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service, must be appended to the E/M service code to indicate its distinct nature.
Critical Care and Global Surgical Procedures
Critical care services can be separately payable alongside procedures with a global surgical period, provided the critical care is unrelated to the surgery. Preoperative and postoperative critical care may be billed in addition to a procedure if the patient is critically ill (meeting the critical care definition), requires the physician’s full attention beyond typical surgical aftercare, and the care is distinctly separate and unrelated to the surgical procedure (common in trauma or burn cases).
When billing critical care in the postoperative period by the surgeon, modifier 24, Unrelated evaluation and management (E/M) service performed by the same physician during the postoperative period, and modifier FT, Unrelated evaluation and management (E/M) visit during a postoperative period, or on the same day as a procedure or another E/M visit, are required to denote the unrelated nature of the critical care. Modifier FT became mandatory for claims from March 1, 2022. If care is fully transferred to another provider (like an intensivist) and is unrelated to the surgery, modifiers 54 Surgical care only and 55 Postoperative management only may also be necessary.
Staying Updated with Critical Care Coding Policies
The landscape of AAPC critical care coding is continually evolving. Staying informed about the latest policy changes, particularly those from CMS and AAPC, is crucial for accurate billing and compliance. Regular review of billing processes, proper use of modifiers, and attention to documentation are key to ensuring providers are educated on the most current Medicare payment policies. Resources like the AAPC website, CMS publications, and payer-specific guidelines are invaluable tools for maintaining expertise in this complex coding area.
Resources:
- CY 2022 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies.
- CMS Transmittal 11181 Pub 100-04 Medicare Claims Processing Manual, Jan. 14, 2022.
- CMS Transmittal 11195 Pub 100-04 Medicare Claims Processing Manual, Jan. 20, 2022.
- Noridian Healthcare Solutions, Critical Care Services, retrieved May 27, 2022.
