The landscape of medical coding is ever-evolving, and critical care coding is no exception. For 2023, the Centers for Medicare & Medicaid Services (CMS) have implemented revisions to critical care billing rules that healthcare providers and coders need to understand to ensure accurate and compliant billing practices. These updates, effective January 1, 2023, introduce significant changes, particularly regarding split/shared services and the aggregation of time spent by practitioners. This article breaks down the critical care coding changes for 2023, providing a clear guide to the updated guidelines.
Key Changes in Critical Care Coding for 2023
Several key modifications have been introduced that impact how critical care services are billed. Understanding these changes is crucial for healthcare practices to maintain compliance and optimize reimbursement.
Split/Shared Services are Now Permitted
One of the most significant updates is the allowance of split/shared services for critical care. Previously, under the 2021 guidelines (effective 2022), split/shared services were not permitted for critical care billing. However, for 2023, CMS now allows for critical care services to be billed as split/shared when both physicians and Non-Physician Practitioners (NPPs) from the same group are involved in delivering care to a patient on the same day. To properly bill for split/shared services, the new FS modifier is required.
Time Aggregation for Same Group Practices
Another major change for critical care coding in 2023 is the ability to combine the times spent by physicians and NPPs within the same group practice when calculating total critical care time. Under the previous guidelines, this aggregation was not allowed. Now, for practitioners in the same group, the total time spent by physicians and NPPs can be combined to meet the 30-minute threshold required for billing codes 99291 and 99292. This aggregation includes the 30-minute threshold, meaning that even partial contributions can now be combined.
NPP Specialty Definition Adjustment
For critical care services, NPPs are no longer considered to have their own specialty in the context of billing. Instead, for critical care coding purposes, an NPP is now considered to be practicing within the same specialty as the physician they are working with. This change impacts how NPP services are documented and billed within critical care settings, requiring attribution to the physician’s specialty.
Clarification on Continuous Critical Care Services Across Midnight
The 2023 guidelines provide clearer direction on billing for continuous critical care services that extend beyond a midnight bill date. CMS has specified that when critical care services are continuous and start on one calendar date and extend into the next, the total time for these continuous services should be billed on the date the service initially began. This clarification simplifies billing for services that span across multiple days, provided they are uninterrupted. For services that are not continuous, billing should occur on the respective dates the services were rendered.
Unchanged Critical Care Billing Practices
While significant changes have been introduced, several critical care billing practices remain consistent from previous years.
Evaluation and Management (E/M) Billed on the Same Day as Critical Care
Billing an E/M code on the same day as critical care remains permissible, especially if the E/M service occurs before the onset of a condition requiring critical care. This includes Emergency Department (E.D.) visits. When billing both E/M and critical care on the same day, it’s essential to use the 25 modifier on the critical care service code to indicate that the E/M service was distinct and occurred prior to the critical care need.
Multiple Critical Care Services by Different Specialties on the Same Day
The rule allowing more than one critical care service to be billed for the same patient on the same day by practitioners from different specialties remains unchanged. If practitioners from different specialties provide critical care to the same patient on the same day, each can still bill for their respective critical care services.
E/M Code Bundling with Anesthesia CPTs
The bundling of Evaluation and Management (E/M) codes with Anesthesia CPT codes continues to be in effect. This means that, with the exception of critical care codes 99291 and 99292, E/M codes are bundled with anesthesia services and cannot be unbundled or billed separately when performed on the same date. Attempts to unbundle will result in denials.
Specifics of Billing Split/Shared Critical Care Services
With the introduction of split/shared billing for critical care, it’s essential to understand the specific requirements. For split/shared services, the critical care times of physicians and NPPs from the same group are aggregated to determine if the time thresholds for 99291 and 99292 are met. It’s important to note that only one practitioner per specialty, per group, can bill for critical care services on a given day.
The practitioner who provides the substantive portion of the critical care service is the one who should bill for the service. The substantive portion is defined as more than 50% of the total combined time reported by the physician and NPP. For example, if a physician provides 16 minutes of critical care and an NPP provides 15 minutes, the physician would be considered to have provided the substantive portion and would bill for the service. In cases involving more than two practitioners, the one with the most reported time is designated as the billing practitioner. The FS modifier must be appended to claims for split/shared critical care services.
It’s crucial to remember that while times are aggregated for determining code levels, only one initial critical care code (99291) can be billed per group, per day, regardless of the total time spent by individual practitioners. Code 99292, for each additional 30 minutes of critical care, can be billed if the total combined time exceeds 74 minutes (requiring at least 104 minutes for 99291 and one unit of 99292).
NPPs and Specialty Considerations for Critical Care
As previously mentioned, NPPs are no longer considered their own specialty for critical care coding in 2023. When NPPs provide critical care services, their documentation should be attributed to the specialty of the supervising physician they are working with. This change in definition is important for proper claim submission and compliance.
Billing for Critical Care Services Across Different Group Practices
Practitioners from different group practices do not aggregate their times. Each group practice will bill separately for critical care services provided. This practice remains unchanged from prior years. However, within each group practice, time aggregation rules apply as described earlier for physicians and NPPs within the same group.
Critical Care Services Spanning Calendar Dates
For critical care services that begin on one calendar date and continue continuously into the next, the total time should be billed on the initial date of service. It is essential to clearly document in the medical record whether the critical care service was continuous. If the services are not continuous, the time spent on each calendar date must be documented and billed for each respective date. For discontinuous services, it is recommended to note in the documentation when the service was paused and when it resumed on the subsequent day.
Reminder on Evaluation and Management Code Bundling with Anesthesia
It is important to reiterate that Anesthesia CPT codes have a modifier indicator “0” bundling edit, which prevents the unbundling of most E/M codes (excluding 99291 and 99292). Therefore, separately billing E/M codes (other than 99291 and 99292) on the same date as anesthesia services will lead to denials. Coders should avoid separate billing of these E/M codes unless they are critical care codes. However, services like peripheral nerve blocks for post-operative pain management may be billable if properly documented and appended with a modifier to unbundle the service.
Additional Considerations for Critical Care Coding 2023
When bedside procedures are performed during critical care consultations, the time spent on these procedures should be excluded from the critical care consultation time. Clear documentation is essential to differentiate between these independent services. Consultations provided by NPPs should include appropriate modifiers, and the total billed critical care consultation time should not exceed 24 hours or the total shift time, unless the service is continuous and spans two calendar days. Finally, it’s crucial to remember that private payer ICU billing rules may differ from Medicare guidelines. Always verify specific contracted terms with individual payers.
Conclusion
The critical care coding changes for 2023 represent a significant shift, particularly with the introduction of split/shared billing and time aggregation for same-group practitioners. Staying updated with these changes is paramount for accurate medical coding and billing in critical care settings. Healthcare providers and coding professionals must familiarize themselves with these revised guidelines to ensure compliance, optimize reimbursement, and maintain efficient revenue cycle management. Understanding these nuances of Critical Care Coding 2023 is essential for all stakeholders in the healthcare billing process.
