Critical care medicine specialists diagnose and treat a wide variety of diseases. A multidisciplinary team approach is needed to care for critically ill patients. Though there are only two codes for critical care services, reporting critical care presents a challenge because of the rules and regulations involved. In fact, Medicare and commercial payers scrutinize the manner in which critical care services are billed. Documentation of medical necessity is crucial. Physicians can rely on expert coding and critical care medical billing services to bill critical care correctly based on the documentation.
Understand what Constitutes Critical Care and Document Medical Necessity
Critical care services are the professional services provided to patients with a critical illness or injury. To report the services accurately, it is necessary to understand what constitutes critical care.
Both CPT and Medicare have provided definitions of critical care. According to CPT 2017, “Critical care is the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.”
Medicare and other payers add that critical care should be medically necessary as “the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.”
Medical necessity is defined by Medicare as “health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” The documentation must clearly convey the reasons why the diagnostic and treatment decisions were made.
Common conditions that require critical care are:
- Heart problems
- Lung problems
- Organ failure
- Brain trauma
- Blood infections (sepsis)
- Drug-resistant infections
- Serious injury (car crash, burns)
How can a practitioner determine what constitutes critical care? The Society of Critical Care Medicine (SSCM) cautions that when reporting services, physicians should ensure that the patient meets the definition of critical care. There are many instances where the patient may be in the critical care unit, but does not meet the critical care criteria. For instance, a patient receiving chronic ventilation in the critical care unit may not be considered critical unless they meet the critical care definition.
There are two CPT codes for adult critical care services:
- 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30–74 minutes
- 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes
Code 99291 stands for the first 30-74 minutes of critical care on a given date and should be used only once per date even if the time spent by the physician is not continuous on that date. Code 99292 is used to report additional blocks of time, of up to 30 minutes each beyond the first 74 minutes in a calendar day.
The following Medicare Learning Network’s MLN Matters #MM5993 chart highlights the time-based billing for critical care services.
|Total Duration of Critical Care
|Appropriate CPT Codes
|Less than 30 minutes
|99284 or 99285
|30 – 74 minutes
|99291 x 1
|75 – 104 min
|99291 x 1 and 99292 x 1
|105 – 134 min
|99291 x1 and 99292 x 2
|135 – 164 min
|99291 x 1 and 99292 x 3
|165 – 194 min
|99291 x 1 and 99292 x 4
|194 minutes or longer
|99291 – 99292 as appropriate
To report these codes, the physician’s documentation must support the critical care claim with details such asthe patient’s condition, services provided, time spent rendering care, and any other relevant information
According to AMA CPT 2017 and CMS Publication 10-4, chapter 12, section 3.6.12, the total time per day must be documented (when reporting 99291 or 99292). Here is important guidance about documenting time as provided by the SCCM:
- There is no specific rule that start times and stop times for critical care must be documented for Medicare patients.
- The documentation should reflect that the time spent performing procedures or services not included in critical care, was not counted.
- Bedside procedures that were performed on the same day as critical care can be reported separately. To get paid for the procedure, the critical care service should be reported with modifier 25 to indicate that the E/M service is significantly and separately identifiable from the procedure.
- If a procedure performed is included in critical care services (e.g., gastric intubation CPT codes 42752 or 42752), the time for performing the procedure must be included in the physician’s critical care time. The procedure must not be reported separately because it is bundled into critical care.
- To report critical care time, the physician or nonphysician provider must be immediately available to the patient.
- Only one practitioner can bill for critical care during a specific time period though more than one physician is managing the patient.
- Critical care can be intermittent and provided at various times during a particular day. To bill services for the particular date of service, all time for that date should be totaled and reported based on total time.
Physicians must also know when time involved with family members or other surrogate decision makers may be counted toward critical care.
When it comes to critical care services, the red flags that will attract the attention of insurance carrier auditors are inaccurate coding, insufficient or lack of documentation, nonadherence to payer policies, and lack of medical necessity. Unbundling procedures included in critical care or overuse of modifiers can also trigger an audit. The following best practices can reduce risk of payer audits:
- Ensure accurate and up-to-date CPT and ICD-10 codes in claims. An experienced physician billing service provider can help with this.
- Provide comprehensive documentation that supports the services that have been performed and billed.
- Make sure documentation can support medical necessity for all billed services.
- Be familiar with Medicare and private payer rules and policies on billing critical care services.
- Avoid over utilization of critical care services, Unbundling services inappropriately with modifier 25 0r 59, billing for critical care when the patient does not meet the critical care definition, and other high-risk coding behavior.
- Perform regular self-audits of procedures and E/M coding and documentation for errors and areas of risk.
Partnering with an experienced critical care medical billing service provider is a practical way to ensure accurate reporting and avoid audits.