Billing for critical care visits is challenging due to various factors affecting billing scenarios and code selection. When you are billing for critical care visits, you should be aware of billing scenarios for single physician/ non-physician practitioner (NPP); concurrent service by different specialties; billing for same specialty and same group; split (or shared) critical care billing; and critical care visits and global surgery. Before going in details billing for critical care visits, let’s define critical care.
Defining Critical Care
As per CPT codebook, the 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.
The critical care may be furnished on multiple days, and is typically furnished in a critical care area, which can include an intensive care unit or emergency care facility. Critical care requires the full attention of the physician or non-physician practitioner (NPP) and therefore, for any given time period spent providing critical care services, the practitioner cannot provide services to any other patient during the same period of time. Services like interpretation of cardiac output measurements, chest X rays, pulse oximetry, blood gases are bundled with critical care services and are not separately payable. Such services are not separately billable by a practitioner during the time-period when the practitioner is providing critical care for a given patient. Time spent performing separately reportable procedures or services should be reported separately and should not be included in the time reported as critical care time.
1. Single Physician or Non-Physician Practitioner (NPP)
When a single physician or non-physician practitioner (NPP) furnishes 30 -74 minutes of critical care services to a patient on a given date, the physician or NPP should report CPT 99291. This code will be used only once per date even if the time spent by the practitioner is not continuous on that date. Thereafter, add on code 99292 can be used for additional 30- minute time increments provided to the same patient. CPT codes 99291 and 99292 will be used to report the total duration of time spent by the physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the practitioner on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated. For continuous services that extend beyond midnight, the physician will report the total units of time provided continuously. Any disruption in the service, however, creates a new initial service.
2. Concurrent Service by Different Specialties
Concurrent care is when more than one physician renders services that are more extensive than consultative services during a period of time. A critically ill patient might require more than one medical condition requiring diverse, specialized medical services and requiring more than one practitioner, each having a different specialty, playing an active role in the patient’s treatment. The reasonable and necessary services of each physician furnishing concurrent care is covered when each plays an active role in the patient’s treatment. Medicare policy allows critical care visits furnished as concurrent care (or concurrently) to the same patient on the same date by more than one practitioner in more than one specialty (for an example, an internist and a surgeon, allergist and a cardiologist, neurosurgeon and NPP), regardless of group affiliation, if the service meets the definition of critical care and is not duplicative of other services.
3. Billing for Same Specialty and Same Group
Physician(s) or NPP(s) in the same specialty and in the same group may provide concurrent follow-up care, such as a critical care visit subsequent to another practitioner’s critical care visit. This may be as part of continuous staff coverage or follow-up care to critical care services furnished earlier in the day on the same calendar date. In the situation where a practitioner furnishes the initial critical care service in its entirety and reports CPT code 99291, any additional practitioner(s) in the same specialty and the same group furnishing care concurrently to the same patient on the same date report their time using the code for subsequent time intervals (CPT code 99292).
CPT code 99291 will not be reported more than once for the same patient on the same date by these practitioners. This insurance carriers recognizes that multiple practitioners in the same specialty and the same group can maintain continuity of care by providing follow-up care for the same patient on a single date. When one practitioner begins furnishing the initial critical care service, but does not meet the time required to report CPT code 99291, another practitioner in the same specialty and group can continue to deliver critical care to the same patient on the same date. The total time spent by the practitioners is aggregated to meet the time requirement to bill CPT code 99291.
4. Billing for Split (or Shared) Critical Care
In the context of critical care, split (or shared) visits occur when the total critical care service time furnished by a physician and NPP in the same group on a given calendar date to a patient is summed, and the practitioner who furnishes the substantive portion of the cumulative critical care time reports the critical care service(s). In such case, the billing practitioner bills the initial service (CPT 99291) and any add-on codes(s) for additional time (CPT 99292).
To bill split (or shared) critical care services, the billing practitioner first reports CPT code 99291 and, if 75 or more cumulative total minutes are spent providing critical care, the billing practitioner reports one or more units of CPT code 99292. While billing Medicare, modifier -FS (split or shared E/M visit) must be appended to the critical care CPT code(s) on the claim. Consistent with all split (or shared) visits, when two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, the time can be counted only once for purposes of reporting the split (or shared) critical care visit.
5. Critical Care and Other Same-Day E/M Visits
The physicians in the same group who are in the same specialty must bill and be paid for services as though they were a single physician. If more than one E/M visit is provided on the same date to the same patient by the same physician, or by more than one physician in the same specialty in the same group, only one E/M service may be reported, unless the E/M services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. This general policy is intended to ensure that multiple E/M visits for a patient on a single day are medically necessary and not duplicative.
However, in situations where a patient receives another E/M visit on the same calendar date as critical care services, both may be billed (regardless of practitioner specialty or group affiliation) as long as the medical record documentation supports that:
- the services were medically necessary
- the other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care, and
- the services were separate and distinct, with no duplicative elements from the critical care services provided later in the day.
For billing Medicare, practitioners must use modifier -25 (same-day significant, separately identifiable evaluation and management service) on the claim when reporting these critical care services.
6. Critical Care Visits and Global Surgery
Critical care visits are sometimes needed during the global period of a procedure, whether pre-operatively, on the same day, or during the post-operative period. In some cases, pre-operative and post-operative critical care visits are included in procedure codes that have a global surgical period. In those cases where a critical care visit is unrelated to the procedure with a global surgical period, critical care visits may be paid separately in addition to the procedure.
Pre-operative and/or post-operative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (for example, trauma, burn cases). When the critical care service is unrelated to the procedure, append the modifier -FT ((unrelated evaluation and management (E/M) visit on the same day as another E/M visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable).
Legion Healthcare Solutions is a leading medical billing company providing complete billing and coding services. We referred Medicare guidelines as most payers consider Medicare guidelines as base. Still, you are advised to check payer-specific billing guidelines and patient insurance coverage for accurate billing. In case of any assistance needed in billing and coding for your practice, contact us at 727-475-1834 or email us at email@example.com