The 2022 updates to Medicare’s Physician Fee Schedule (MPFS) brought significant changes to critical care service coding. Aligning with CPT® guidelines in most areas, these revisions redefine critical care, specify qualified healthcare professionals (QHPs) who can provide these services, and clarify what services are bundled and not separately billable. Understanding these crucial updates, particularly regarding CPT® code 99292, is paramount for healthcare providers to ensure accurate claim submissions and appropriate reimbursement.
Defining Critical Care in 2022: Adopting CPT® Standards
CMS has adopted the CPT® definition of critical care services within the 2022 MPFS final rule, setting a clear standard for medical necessity and coding accuracy. According to CPT®, critical care is:
… 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. Furthermore, CMS aligns with CPT® by recognizing that both physicians and nonphysician practitioners (NPPs) who qualify as QHPs can report critical care services. A QHP is defined by CMS as an individual deemed qualified through education, training, licensure/regulation where applicable, and facility privileging when necessary, operating within their defined scope of practice. This broadens the scope of who can bill for these vital services, reflecting the collaborative nature of modern healthcare teams.
Reporting Critical Care: Navigating CPT® Codes 99291 and 99292
The cornerstone of critical care coding in 2022 remains 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 crucial to remember that time spent on separately reportable procedures or services should not be included in the reported critical care time. Accurate time tracking is essential for compliant billing.
Handling Continuous Care Across Dates of Service:
The 2022 MPFS final rule incorporates CPT® guidance on services extending past midnight. A continuous critical care service that extends into the next calendar day does not initiate a new “first hour.” However, any interruption in the service will create a new initial service period. This is analogous to services like intravenous hydration, where time is aggregated across dates without resetting the initial hour unless a service disruption occurs.
Concurrent Critical Care by Different Specialties:
Medicare recognizes the complexity of critical care scenarios and allows for concurrent critical care services provided to the same patient on the same date by practitioners of different specialties. This is permissible regardless of group affiliation, provided each service meets the definition of critical care and is not duplicative. CMS emphasizes that “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,” acknowledging the need for multidisciplinary approaches in critical situations.
Concurrent Critical Care by Same Specialty and Group:
When multiple practitioners within the same specialty or group furnish critical care concurrently to a single patient on the same day, specific coding rules apply. Code 99291 should be reported for the initial critical care provided by an individual physician or NPP. Subsequent critical care in such scenarios is reported using 99292.
A key point of divergence from standard CPT® guidelines arises when the initial practitioner does not meet the minimum time requirement for 99291 (first 30-74 minutes). In these cases, another practitioner from the same specialty or group can continue providing medically necessary care. The total time spent by all practitioners is then aggregated to meet the time threshold for reporting 99291. Crucially, 99292 should not be reported until an additional 30 minutes of critical care time (totaling 104 minutes or more) are furnished to the patient on the same day. This nuanced approach from CMS requires careful attention to time documentation and group billing practices.
Bundled Services: What’s Included in Critical Care?
CPT® 2022 introduced prefatory language that bundles several common services into critical care, meaning they are not separately payable when performed concurrently with critical care. These bundled services encompass:
- 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
Comprehensive documentation remains vital to justify the necessity and extent of critical care provided, ensuring clarity regarding each practitioner’s role in the patient’s treatment.
Split/Shared Critical Care Visits: A 2022 Policy Change
A significant shift in 2022 is the allowance of billing critical care services as split/shared evaluation and management (E/M) services, effective for dates of service on or after January 1, 2022. This means that when both a physician and an NPP contribute to critical care, the practitioner who performs the “substantive portion” of the total critical care time can bill for the service. CMS defines “substantive” as “more than half the cumulative total time in qualifying activities included in CPT codes 99291 and 99292.”
In split/shared scenarios, if practitioners jointly spend time with the patient or discuss the case together, this time is counted only once. To correctly identify these split/shared services between a physician and NPP, modifier FS Split (or shared) evaluation and management visit must be appended to the critical care code.
Important Update for 2023: As of January 1, 2023, CMS guidance clarifies that for billing split/shared critical care, the billing practitioner first reports CPT code 99291. If the cumulative total critical care time reaches 104 minutes or more, then one or more units of CPT code 99292 are reported. This update reinforces the time-based nature of critical care coding and the sequential use of 99291 and 99292.
Critical Care and E/M Services on the Same Day
CMS now permits payment for both critical care and a separate E/M visit by the same practitioner(s) within the same specialty or group on the same date of service. However, strict documentation is required. The practitioner must clearly document that the hospital E/M service was provided at a distinct time when the patient did not require critical care and that the E/M service was separate and distinctly identifiable from any critical care services furnished later that day. In these instances, 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 when reporting both services.
Critical Care Visits and Global Surgical Procedures
Critical care services can be separately reimbursed even when performed during a global surgical period, provided the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be additionally payable if the patient is critically ill (meeting critical care definition), requires the physician’s full attention, and the care is demonstrably above and beyond and unrelated to the surgical procedure itself (common in trauma or burn cases). Thorough physician documentation is crucial to substantiate the separate and distinct nature of the critical care service.
When billing critical care services in conjunction with global surgeries, 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 essential. Modifier FT, effective January 1, 2022, became mandatory on claims from March 1, 2022.
It’s important to note that if 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 to the surgery), modifiers 54 Surgical care only and 55 Postoperative management only must also be reported to reflect the transfer of care.
Staying Current with Critical Care Coding
The 2022 MPFS final rule updates offer essential clarification for practitioners on the appropriate use of critical care service codes. To ensure ongoing compliance and accurate reimbursement, healthcare providers must diligently review their billing processes, understand the application of new and existing modifiers, and address any documentation gaps. Educating coding and billing staff on these latest Medicare payment policies is a critical step in navigating the complexities of critical care coding.
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.
[
