Navigating the complexities of critical care coding can be challenging, especially with evolving guidelines and payer policies. For healthcare professionals aiming for accurate and compliant billing, understanding the nuances of critical care coding, particularly as defined by AAPC (American Academy of Professional Coders) and Medicare, is crucial. This guide, drawing on expert insights and official sources, clarifies the essential aspects of critical care coding to ensure proper reimbursement and adherence to the latest standards.
Defining Critical Care Services: What AAPC and Medicare Say
Critical care services are not just about the location of care but the intensity of care provided to a patient. Both AAPC and Medicare align with the CPT® definition, emphasizing the severity of the patient’s condition. Critical care is defined as the direct delivery of medical care by a physician or qualified healthcare professional (QHP) for a critically ill or injured patient. This involves acute impairment of one or more vital organ systems, creating a high probability of imminent or life-threatening deterioration. The care necessitates high complexity decision-making to manage organ system failure or prevent further life-threatening complications.
For accurate critical care coding, remember these key components of the definition:
- Critically Ill Patient: The patient must be critically ill with acute impairment of organ systems and a high risk of deterioration.
- High Complexity Decision Making: The medical decision-making must be of high complexity to manage the patient’s critical condition.
- Qualified Healthcare Professional (QHP): Services must be provided by a physician or other QHP, as defined by CMS, working within their scope of practice.
CPT® Codes 99291 and 99292: Reporting Critical Care Time
The cornerstone of critical care coding lies in the appropriate use of CPT® codes 99291 and 99292. These codes are time-based and used to report the total duration of critical care service provided on a given date.
- 99291 (Initial Critical Care): Used for the first 30-74 minutes of critical care.
- 99292 (Additional Critical Care): Reported for each additional 30 minutes beyond the initial 74 minutes.
It’s vital to accurately document the total critical care time, which can be continuous or aggregated. However, time spent on separately reportable procedures should not be included in the critical care time calculation.
Scenario: Continuous Care Spanning Dates
When critical care extends past midnight, the service period doesn’t reset for the initial hour. For instance, if critical care is provided from 11:00 p.m. to 2:00 a.m., the coding is based on the total continuous hours.
Concurrent Critical Care: Multiple Providers, Same Specialty, and Different Specialties
Critical care can be concurrently furnished by multiple practitioners under specific circumstances.
- Different Specialties: Practitioners from different specialties can provide concurrent critical care to the same patient on the same date, provided each service is medically necessary, meets the definition of critical care, and is not duplicative. Each practitioner must play an active and necessary role in the patient’s treatment, and this must be clearly documented.
- Same Specialty, Same Group: Multiple practitioners within the same specialty or group can also furnish concurrent critical care. For initial critical care in such scenarios, report 99291 for the physician or NPP who begins the care. Subsequent critical care by others in the same specialty or group should be reported using 99292. Time from multiple providers in the same group and specialty can be aggregated to meet the time threshold for 99291 and 99292.
Services Bundled into Critical Care: What’s Not Separately Billable
Understanding what services are bundled into critical care is crucial to avoid unbundling errors. CPT® guidelines specify that certain services, when provided during the critical care period, are considered part of the critical care and are not separately payable. These bundled services include:
- Cardiac Output Measurements: Interpretation of measurements (93561, 93562).
- Chest X-rays: (71045, 71046).
- Pulse Oximetry: (94760-94762).
- Blood Gases and Data Interpretation: Blood gases and interpretation of physiologic data like ECGs, blood pressures, and hematologic data.
- Gastric Intubation: (43752, 43753).
- Temporary Transcutaneous Pacing: (92953).
- Ventilator Management: (94002-94004, 94660, 94662).
- Vascular Access Procedures.
When coding for critical care, ensure that bundled services are not billed separately unless they are distinctly separate and unrelated to the critical care condition. Proper documentation is key to justifying separate billing if applicable.
Split/Shared Critical Care Visits: Billing and Modifier Use
Split or shared visits, involving both a physician and a non-physician practitioner (NPP), are permissible in critical care coding. For services on or after January 1, 2022, the practitioner who performs the substantive portion of the critical care time can bill for the entire service. “Substantive” is defined as more than half of the total cumulative time spent in qualifying critical care activities.
When billing for split/shared critical care, append modifier FS, Split (or shared) evaluation and management visit, to the critical care code. Remember that when time is jointly spent by both practitioners discussing the patient, it should only be counted once in the total time.
Update for 2023: As of January 1, 2023, to bill split/shared critical care, the billing practitioner reports 99291 initially and then 99292 for every additional 30 minutes of critical care beyond the initial 74 minutes, if the total cumulative time is 104 minutes or more.
Critical Care and E/M Services: Coding Concurrently
It is possible to bill for both critical care and a separate Evaluation and Management (E/M) visit by the same practitioner on the same day, provided certain conditions are met. The E/M service must be distinct and separately identifiable from the critical care service. It should be provided at a time when the patient did not require critical care and must be for a different clinical purpose.
To report both services, append modifier 25, Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service, to the E/M code. Documentation must clearly support the necessity and distinct nature of both the E/M service and the critical care.
Critical Care and Global Surgical Procedures: Coding Considerations
Critical care services can be separately reimbursed even when performed during the global period of a surgical procedure, given they are unrelated to the surgery. Preoperative or postoperative critical care can be billed separately if the patient is critically ill and requires intensive care that is beyond the typical care associated with the surgical procedure. Cases such as trauma or burns often justify separate critical care billing in surgical contexts.
To ensure proper billing in these scenarios, critical care should be billed with 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. Modifier FT became mandatory for claims starting March 1, 2022.
If critical care during a postoperative period is transferred from the surgeon to an intensivist and is unrelated to the surgery, modifiers 54 (Surgical care only) and 55 (Postoperative management only) should also be reported to indicate the transfer of care.
Staying Updated: The Key to Accurate Critical Care Coding
The rules and guidelines surrounding critical care coding are subject to change. Staying informed about the latest updates from Medicare, AAPC, and CPT® is essential for accurate and compliant coding. Regularly reviewing official publications and resources will help ensure your billing practices align with current policies, optimizing reimbursement and minimizing compliance risks.
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.
By keeping your knowledge current and processes aligned with these guidelines, you can confidently navigate the complexities of critical care coding and ensure accurate reimbursement for the critical services provided to patients.
