Every year, more than 5 million patients are admitted to intensive care units (ICUs) in the U.S., according to the Society of Critical Care Medicine (ACCM). People admitted to ICU have life-threatening injuries and illnesses that need 24-hour care, continuous monitoring of vital signs, and specialized treatments. The 2022 Medicare Physician Fee Schedule (MPFS) final rule introduced policy changes that included a new definition of critical care services, guidance on which health care professionals can provide these services in various settings, and what is included in the services and not separately payable. Physicians can rely on outsourced critical care medical billing services to stay up to date with these changes and submit correct claims to get paid for these services.
An acute impairment, an incident that leads to the need for critical care, or life-saving procedure(s) would apply to critical care services. The provider’s service must be medically necessary and meet the definition of critical care services as described below in order to be considered covered.
What Critical Care Covers
Medicare has now adopted CPT’s definition of critical care, which 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”.
All other types of services provided to patients in intensive care would be billed under the procedure codes relevant to the service(s) provided.
Factors expected in the critical care context (https://med.noridianmedicare.com) are:
- Highly complex clinical decisions usually based on interpretation of complex data and use of advanced technology.
- Clinical decisions addressing organ system failure, or the prevention of further life-threatening deterioration.
- Both the clinical status and the care rendered by the provider are critical in nature.
- All reasonable sites of service are permissible when the clinical condition, the intensity of care and the time spent meet the critical care definition.
Critical care interventions include:
- Intensive or invasive monitoring
- Support of airway, breathing, or circulation
- Stabilization of acute or life-threatening medical problems
- Comprehensive management of injury and/or illness; and
- Maximization of comfort for dying patients
Guidelines for Reporting Critical Care Services in 2023
Keep the following guidelines in mind when billing critical care services:
- Who can provide critical care: Critical care services can be provided by physicians and non-physician practitioners (NPP’s), including nurse practitioners (NPs), physician assistants (PAs), certified nurse specialists (CNSs) and certified nurse midwives (CNMs). Beginning January 1, physician assistants (PAs) are permitted to bill Medicare directly for their professional services, reassign payment for their professional services, and incorporate with other PAs to bill Medicare for PA services. Provision of critical care services must be within each provider’s scope of practice and licensure for the state in which the provider is practicing. A physician assistant (PA) must meet the general physician supervision requirements for the services.Critical care requires the full attention of the physician or 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.
- CPT codes: The critical care codes are:
99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
99292 …each additional 30 minutes (list separately in addition to code for primary service)
- Pay attention to “time“:
Critical care is a time-based service, performed on an hourly or fraction of an hour basis. Payment is not restricted to a fixed number of hours, provider, or days as long as services meet medical necessity standards.
Per the MPFS 2023 final rule: the full timeframe for each code must be met in order to add it to the claim. In critical care, after 74 minutes of cumulative time has been spent, meeting the requirement for CPT 99291, the physician billing the service may report one or more units of CPT 99292 only when another full 30 minutes of time has been spent (74 +30=104). Each 30-minute segment beyond that would support an additional unit of CPT 99292.
CMS stated: “…our policy is that CPT code 99291 is reportable for the first 30-74 minutes of critical care services furnished to a patient on a given date. CPT code 99292 is reportable for additional, complete 30-minute time increments furnished to the same patient (74 + 30 = 104 minutes).” This means that CPT code 99292 could be billed after 104, not 75, or more cumulative total minutes were spent providing critical care.
These codes can be billed for the aggregate time spent during one date, even if the time is non-continuous. For continuous services that extend beyond midnight, the physician or NPP will report the total units of time provided continuously. Any disruption in the service, however, creates a new initial service.
To report critical care services correctly, determine the following:
- For each +99292-eligible critical care encounter, determine where time starts
- When reporting by AMA CPT rules: report 99291 for the first 30 to 74 minutes. At 75 minutes, report +99292
When reporting by Medicare rules: 104 minutes is necessary to fulfill the full 30 minutes of the add-on code to report +99292.
- Critical care services as split/shared services:
Critical care services can now be furnished as split/shared services: CMS recognizes that the total critical care service time provided by a physician and QHP [qualified health care professional] in the same group on the same day can be aggregated. According to the split(or)/shared rule for critical care:
- The practitioner who furnishes more than half of the total critical care time should report the critical care services can bill for the critical care service with modifier FS.
- Billing is based on cumulative time spent and documented by both practitioners.
- Individual units of critical care time can be reported by separate providers within a group over the course of a 24-hour period, that is, a base unit of CPT 99291 can be billed with subsequent units of CPT 99292 by other group members.
- Concurrent critical care services: Critical care services may be furnished as concurrent care to the same patient on the same date by more than one practitioner in more than one specialty, regardless of group affiliation, as long as the services are separate and distinct with no duplicate elements within the critical care service. The visit must be medically necessary.
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While a critical care medical coding company can help providers code their services correctly, proper documentation by physician or NPP of the patient’s condition and services rendered is crucial for appropriate billing and reimbursement..