Decoding the Critical Care Coding Clinic: 2022 Updates and Best Practices

The landscape of medical coding is ever-evolving, and critical care services are no exception. For those working within a critical care coding clinic setting, staying abreast of the latest guidelines is paramount for accurate billing and compliance. Significant policy updates were implemented in the 2022 Medicare Physician Fee Schedule (MPFS) final rule, impacting how critical care services are defined, who can provide them, and what is considered inclusive within these services. This article delves into these crucial changes, particularly concerning CPT® code 99292, to ensure your critical care coding practices are precise and optimized for appropriate reimbursement.

Understanding the Definition of Critical Care in 2022

The Centers for Medicare & Medicaid Services (CMS) aligned with the CPT® definition of critical care visits in the 2022 MPFS final rule, providing a standardized understanding for critical care coding clinic professionals. CPT® defines critical care as:

… the direct delivery by a physician(s) or other qualified healthcare professional (QHP) of medical care for a critically ill/injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminent or life-threatening deterioration of the patient’s condition. It involves high complexity decision making to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.

This definition emphasizes the severity of the patient’s condition and the complexity of medical decision-making required. Crucially, both physicians and nonphysician practitioners (NPPs) who qualify as QHPs are recognized by CMS as eligible to report critical care services. A QHP is defined by CMS as an individual deemed qualified through education, training, licensure/regulation (if applicable), and facility privileging (if applicable), and who operates within their defined scope of practice. This clarification is vital for critical care coding clinic operations, ensuring appropriate recognition of all qualified providers.

Best Practices for Reporting Critical Care Services

For accurate reporting within a critical care coding clinic, it’s essential to understand the nuances of CPT® codes 99291 and 99292, which are designated for critical care services. These codes are used to report the total duration of critical care time, whether continuous or aggregated, furnished by a physician or other QHP on a given service date. It’s important to remember that time spent on separately reportable procedures or services should not be included when calculating critical care time.

Handling Continuous Care Across Multiple Dates

A key point for critical care coding clinic accuracy is understanding how to handle continuous care that extends past midnight. The 2022 MPFS final rule adopted CPT® guidelines stating that when critical care service furnished by a physician or QHP extends beyond midnight into the next calendar date, the service is considered continuous and does not initiate a new “first hour.” However, any interruption in service does constitute a new initial service.

For instance, consider intravenous hydration (codes 96360, 96361) administered from 11:00 p.m. to 2:00 a.m. In this scenario, code 96360 (for the first hour) would be reported once, and 96361 (for each additional hour) would be reported twice, reflecting the continuous nature of the service across dates.

Concurrent Critical Care by Different Specialties

Critical care coding clinic scenarios often involve multiple specialists. CMS clarifies that critical care services can be furnished concurrently to the same patient on the same day by practitioners from different specialties, even within the same group. This is permissible as long as each service independently meets the definition of critical care and is not duplicative.

CMS emphasizes that “The reasonable and necessary services of each physician rendering concurrent care could be covered where each is required to play an active role in the patient’s treatment.” This acknowledgement is crucial for hospitals and larger practices managing complex critical care cases.

Concurrent Critical Care Within the Same Specialty and Group

When multiple practitioners of the same specialty or within the same group provide critical care concurrently to a patient on the same day, specific coding rules apply. For critical care coding clinic staff, it’s vital to note that code 99291 should be reported for the initial critical care provided by the individual physician or NPP. Subsequent critical care provided by others in the same specialty or group should be reported using 99292.

In scenarios where one practitioner initiates medically necessary critical care but doesn’t meet the minimum time requirement for 99291 (30-74 minutes), and another practitioner in the same specialty or group continues care, the total combined time is used to meet the 99291 threshold. It is essential to aggregate their times. Code 99292 is not reported until an additional 30 minutes of critical care time is furnished beyond the initial 74 minutes (totaling 104 minutes or more). This differs from standard CPT® coding book guidance and requires careful attention in a critical care coding clinic setting.

Services Bundled into Critical Care

CPT® 2022 introduced bundled services within critical care, impacting what services can be separately billed when provided alongside critical care. For critical care coding clinic professionals, it’s essential to know these bundled services, which are not separately payable when furnished concurrently with critical care. These include:

Interpretation of cardiac output measurements (93561, 93562)
Chest X-rays (71045, 71046)
Pulse oximetry (94760-94762)
Blood gases and collection and interpretation of physiologic data (e.g., ECGs, blood pressures, hematologic data)
Gastric intubation (43752, 43753)
Temporary transcutaneous pacing (92953)
Ventilator management (94002-94004, 94660, 94662)
Vascular access procedures

Thorough documentation is crucial to justify the necessity and roles of each practitioner involved in the patient’s treatment, particularly when dealing with bundled services within a critical care coding clinic context.

Split/Shared Critical Care Visits

A significant update for critical care coding clinic practices is the allowance of billing critical care services as split/shared evaluation and management (E/M) services, effective since January 1, 2022. The practitioner who performs the “substantive portion” of the total critical care time can now bill for the service. CMS defines “substantive” as more than half of the cumulative total time spent in qualifying activities included in CPT codes 99291 and 99292.

In split/shared critical care scenarios, if multiple practitioners jointly spend time with or discuss the patient, that time is counted only once. To denote split/shared services between a physician and NPP, the new modifier FS, Split (or shared) evaluation and management visit, should be appended to the relevant codes.

Important Update for 2023: As of January 1, 2023, CMS guidelines specify that to bill split (or shared) critical care services, the billing practitioner initially reports CPT code 99291. If the cumulative total critical care time reaches 104 minutes or more, the billing practitioner reports one or more units of CPT code 99292. This update should be integrated into critical care coding clinic protocols.

Billing Critical Care and E/M Services Together

Critical care coding clinic staff should also be aware that CMS now permits payment for both critical care and E/M visits by the same practitioner(s) within the same specialty or group under specific conditions. This is allowed if the practitioner documents that the hospital E/M service was delivered when the patient did not require critical care, and that it was distinct and separate from any critical care services provided later on the same day. When reporting both services, 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 claim.

Critical Care Services in Conjunction with Global Surgeries

Critical care coding clinic professionals should understand the guidelines for billing critical care alongside procedures with global surgical periods. Separate payment for critical care services is possible in addition to a procedure with a global surgical period, provided the critical care is unrelated to the procedure. Preoperative and/or postoperative critical care may be separately payable if the patient meets the critical care definition, requires the physician’s full attention, and the care is beyond and unrelated to the surgical procedure (e.g., in trauma or burn cases). Comprehensive documentation is crucial to clearly demonstrate the separate and distinct nature of these services.

When billing critical care services in these scenarios, 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, should be used to indicate that the critical care was unrelated to the procedure. Modifier FT became effective January 1, 2022, and is mandatory on claims from March 1, 2022.

Note that when critical care is provided in the postoperative period by a provider other than the surgeon, modifiers are generally not needed. However, if care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), modifiers 54, Surgical care only, and 55, Postoperative management only, must also be reported, as per CMS guidelines.

Staying Informed is Critical for Accurate Coding

The 2022 MPFS final rule updates have brought essential clarifications to critical care services coding. For professionals working in a critical care coding clinic, continuous education and process evaluation are vital. Regularly reviewing billing processes, the correct application of new modifiers, and identifying any documentation gaps are crucial steps to ensure your providers are well-versed in the most current Medicare payment policies. This proactive approach will support accurate claims submission and optimal reimbursement for critical care services.

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.

Becky Strom

Becky Strom, CPC, COC, CPCO, MCS-P, has 34 years of experience in the healthcare field. In her current role, she leads a team of certified coding auditors and clinical auditors, whose role is to research coding guidelines and regulations, establish coding policies and procedures in compliance with those regulations, perform audits, and provide education and training to the providers and coders throughout the organization. Strom is a 2022-2024 AAPC National Advisory Board member.