Critical Care Services - JE Part B
Critical Care Services
CMS defines critical care as “the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient” and also defines a critical illness or injury as one that “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.” we have included several examples of critical care situations, provided by CMS.
Critical care may be delivered outside the context of acute clinical crisis, but always requires the imminent risk of further deterioration in a critically ill or injured patient. Factors that are expected in the critical care context 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.
Providers Who May Perform Critical Care
Physicians and qualified NPPs may provide critical care services when care meets the definition and requirements for such services. Provision of these services must be within each provider’s scope of practice and licensure for the state in which the provider is practicing. A PA must meet the general physician supervision requirements for the services.
Unlike other hospital-based services, critical care cannot be performed on a split/shared basis, and each unit of care must be rendered and billed by a solitary provider.
Critical care reflects treatment and management by an individual physician or qualified NPP for the documented time period supporting the service. Individual units of critical care time can be reported by separate same-specialty providers within a group over the course of a 24-hour period, meaning that a base unit of 99291 can be billed with subsequent units of 99292 by other group members.
When a physician or qualified NPP within a group provides “staff coverage” or “follow-up” for each other, after the first hour of critical care on the same calendar date, the subsequent visit by the covering provider (physician or NPP) may be billed with the critical care add-on code 99292. The subsequent visit should be billed with the NPI of the provider performing the subsequent service.
Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician.
CPT code 99291 should be used once per calendar date per patient by the same physician or physician group of the same specialty.
Non-physician practitioners of the same group:
- Physician time may not be combined with a non-physician practitioner of the same group practice.
- Time is billed separately from the physician using the appropriate code.
- May not bill the initial critical care code on the same day as the physician (e.g., if the physician provides 30 - 74 minutes of critical care services, the non-physician practitioner will bill CPT code 99292 for the additional time up to 30 minutes.)
Physicians of a different specialty may each report CPT code 99291 if they are providing care that is unique to his/her individual medical specialty and managing at least one of the patient’s critical illness(es) or critical injury(ies)
Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the initial critical care CPT code (99291). This service should be reported using another appropriate E/M code [ensuring all components of the CPT descriptor are met] such as subsequent hospital care.
Services and Medical Necessity
As with all services approved by Medicare, critical care must be reasonable and necessary, based on the provider’s assessment of a clinical crisis and/or imminent deterioration requiring immediate intervention.
Situations which do not support the necessity of critical care include:
- Care for patients in a critical, intensive, or specialized care unit who are clinically stable and responding favorably to established interventions. Subsequent hospital care codes (99231-99233) may be more appropriate in these circumstances
- Chronic long-term management of patients who are ventilator or dialysis dependent, unless a change in condition threatens the patient’s clinical stability and demands immediate intervention
- Patients admitted to a critical care unit because no other hospital beds were available situations that may not satisfy Medicare medical necessity criteria for critical care services.
- Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose)
- Patients admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit.
- Care for a critically ill patient that is not critical in nature (e.g., dermatological treatment of a minor skin rash for an acutely ill ICU patient)
Note: It is the physician’s or NPP’s documentation of the patient’s condition and services rendered, not the location that determines whether critical care is appropriately billed.
Palliative and Hospice Patients
Critical care services are intended to assess, manipulate, and support vital organ system failure, and to prevent further life-threatening deterioration. These services are appropriate when 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 may rarely be appropriate in the palliative care environment. It may be permissible when an unexpected and acute emergency arises in a hospice patient. In such rare instances, medical record documentation would be expected to support the nature of the clinical problem and the intervention performed by the billing provider.
Time Based Assessment and Documentation
Critical care services are represented by time-based codes, so providers must monitor, and document time spent carefully. Time should be documented as spent (e.g. “70 minutes”) or as clock time (e.g. “8:30 am-9:45 am”). Subjective statements (e.g. “spent a long time with patient and family” or “had a lengthy discussion”) are not acceptable as time documentation.
Time that can be counted includes time spent by the provider in evaluating, treating and managing the patient’s condition, both at the bedside and on the unit while coordinating care, as long as the provider remains immediately available to the patient. Unit time may include review of diagnostic and laboratory findings and discussion with colleagues regarding the patient’s management. Time spent off the unit cannot be counted, since the provider is not immediately available to the patient. In addition, teaching sessions with hospital residents, often performed during rounds, do not count toward critical care time.
Critical care service time must be exclusive to the patient, meaning the provider cannot perform services for other patients during the same timeframe.
Each critical care progress note must include total time spent by the provider while performing the service. Critical care may be provided on the same day (but not during the same time segment) by providers representing different specialties, each of whom must carefully document his/her own role in the care and the time spent. Non-continuous time for medically necessary
Family Counseling and Discussion
When patients are critically ill, providers often routinely discuss daily updates with family members or healthcare proxies. Time spent for these updates is considered part of the pre and post service work of critical care service and does not count toward time spent in actual critical care delivery.
In the following circumstances, face-to-face discussions with family members or proxies can be counted as critical care time. Documentation must reflect the patient’s inability to participate when:
Provider is obtaining a history and the patient is unable or incompetent to participate
Discussion is considered medically necessary in determining treatment decisions
Telephone calls with family or proxies may count toward critical care time, but only when they meet the above criteria (obtaining history and/or determining treatment decisions) and are documented as such.
Note: No other family or proxy discussions, no matter how lengthy, count toward critical care time
Bundled vs Non-Bundled
The following is a list of procedures that are considered bundled into critical care. Time spent performing these services is included in critical care time and these services should not be billed separately from the critical care codes:
|The interpretation of cardiac output measurements||93561, 93562|
|Chest x-rays, professional component||71010, 71015, 71020|
|Blood draw for specimen||36415|
|Blood gases, and information data stored in computers
(e.g., ECGs, blood pressures, hematologic data)
|Gastric intubation||43752, 91105|
|Pulse oximetry||94760, 94761, 94762|
|Temporary transcutaneous pacing||92953|
|Ventilator management||94002 - 94004, 94660, 94662|
|Vascular access procedures||36000, 36410, 36415, 36591, 36600|
Procedures not identified on this list are not bundled into critical care and may be billed separately when medical necessity expectations are met and there is proper documentation.
In addition, please note that time spent performing nonbundled procedures (e.g. spinal tap, endotracheal intubation) cannot be counted toward critical care time, since these procedures are
Emergency Room (ER) Services or Critical Care
If an appropriate emergency room code exists and the standard of care can reasonably be provided within those codes, the 99282- 99285 should be utilized by the ER physician.
Critical care codes maybe be used if the nature of the patient’s condition meets the critical care definition then only the critical care code (99291) should be billed not both
A Level 5 ER visits last requirement is similar to a requirement for Critical Care Services: “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. “Both codes therefore apply to similar patient circumstances and both require “high complexity decision making”, so the question will occasionally arise of when one code should be used instead of the other. The distinction is in the documentation of the duration, nature and necessity of the time spent personally providing one-on-one critical care services to that critically ill patient. specifically, in contrast to the typical team approach to a variety of patients in an Emergency Room setting: “For any given period of time spent providing critical care services, the individual must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.”
The record must make it clear that, for this critically ill patient, this full-time focus on the individual patient was necessary for, and was provided for, the full documented cumulative period of time, personally providing necessary critical care services. If the documentation does not convincingly establish that, these criteria were met and for a duration clearly qualifying as critical care time, it is not appropriate to claim as critical care. However, it may remain quite appropriate to claim as 99285 if the criteria are met.
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, providers or days as long as services meet medical necessity standards. The following CMS guidelines apply:
- Critical care time may be aggregated over a 24-hour period
- Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient.
- Providers (who may be referred to as intensivists or ICU hospitalists) are often employed by the hospital on a “shift” or “per day” basis. “On duty” hours in a critical care unit have no correlation to critical care services as paid under the Medicare Part B Fee Schedule. Critical care time is paid on a per patient/per service basis and each unit of billing must be supported by a medical record describing the specific nature and time for the service rendered.
- CPT 99291 represents the first 30-74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient by the same physician of the same specialty, or a qualified NPP. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician and would not each report CPT 99291 on the same date of service.
- CPT 99292 represents additional block(s) of time, of up to 30 minutes each, beyond the first 74 minutes of critical care. The service may represent aggregate time met by a single physician or members of the same group practice with the same medical specialty.
- Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E&M code such as subsequent hospital care
- When an ED patient requires critical care services, only the critical care codes (99291-99292) may be reported as an E&M service. An ED visit code (E&M) may not also be reported by the same provider or another provider of the same group on the same day as critical care service.
- When critical care services are provided by the same provider or group on the same date as other E&M services (office, hospital inpatient or outpatient), both the E&M and critical care service may be payable. Providers are advised to submit documentation upon request supporting the two services.
- Critically ill or critically injured patients may require the care of more than one physician medical specialty. Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time.
- Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the initial critical care CPT code (99291). This service should be reported using another appropriate E/M code [ensuring all components of the CPT descriptor are met] such as subsequent hospital care.
Time Increments for Critical Care Codes
The following table demonstrates the correct per time increment:
|Less than 30 minutes||99232 or 99233 or other appropriate E&M code|
|30-74 minutes||99291 x 1|
|75-104 minutes||99291 x 1 and 99292 x 1|
|105-134 minutes||99291 x1 and 99292 x 2|
|135-164 minutes||99291 x 1 and 99292 x 3|
|165-194 minutes||99291 x 1 and 99292 x 4|
|194 minutes or longer||99291-99292 as appropriate (per the above illustrations)|
Critical care must be medically necessary; involved high complexity decision making
- Was the physician called to see the patient on an emergency basis?
- Does the physician’s note support evidence of threat of imminent deterioration of patient’s condition?
- Is the critical illness or injury acutely impairing one of more body systems?
- Was the physician’s services required to prevent further decline of life-threatening conditions?
- Does the documentation indicate that an assessment of the patient and services of the physician were provided to support vital functions?
- Does the documentation support that the provider was either at beside or immediately available?
- Family discussions may be considered part of the critical care time when documentation supports:
- Patient is unable to participate in giving history
- Discussions are related to determining medically necessary treatment decisions
- A summary of the medical necessity and/or content of the discussion.
Relative to Global Surgery and Other Procedures
Critical care services are usually not payable to a physician who bills a procedure code with a global surgery period on the same date of service. In unusual circumstances, when pre and postoperative care by the surgical provider is beyond customary parameters, critical care can be billed with a modifier 25. The physician’s note would be expected to fully document the separate and distinct nature of the critical care service.
When critical care is performed in the postoperative period by a provider other than the surgeon, no modifier is necessary. However, when the performing surgeon transfers patient responsibility in the global postoperative period, critical care billing by the surgeon should be billed with modifier 54 (surgical care only). When the receiving provider (e.g., an intensivist) bills critical care services, modifier 55 (postoperative management only) should be appended to the service lines. Documentation must clearly reflect the transfer of care by the operating surgeon to the other provider.
Separate payment may also be made for endotracheal intubation (CPT 31500), insertion of a flow-directed catheter (CPT 93503) and CPR (CPT 92950. Critical care should be reported with a modifier 25 in these circumstances, although time spent on the procedures cannot be counted toward critical care time. For example, a physician may spend 60 minutes at the bedside of a critically ill patient, spending 10 minutes on CPR, 20 minutes for Swan-Ganz insertion and 15 minutes on endotracheal intubation. The 45 minutes spent on these separately payable procedures does not count toward critical care time, leaving a balance of 15 minutes, which is insufficient to bill a unit of critical care.
Trauma and Burn Cases
When treating patients for trauma or burn injuries, preoperative and postoperative critical care may be payable along with the global surgical fee. This concept applies when the patient is critically ill and requires the treating physician’s full attention, and the critical care is unrelated to the specific injury or surgical procedure performed. In such circumstances, the medical record should reflect a situation in which there is a significant probability of imminent or life-threatening deterioration in the patient’s condition, and that the critical care was unrelated to the prior surgery.
For critical care of this nature, append these modifiers as appropriate:
- Preoperatively: Modifier 25 is appended to the critical care code(s).
- Postoperatively: Modifier 24 is appended to the critical care code(s).
Teaching physician care must meet both the critical care and the teaching physician criteria in addition to the following:
Teaching Time spent teaching may not be counted towards critical care time. Time spent by the resident, in the absence of the teaching physician, cannot be billed by the teaching physician as critical care or other time-based services. Only time spent by the resident and teaching physician together with the patient or the teaching physician alone with the patient can be counted toward critical care time.
The documentation must support the teaching physician and the resident were both present for the entire critical care time billed.
Medical record documentation may reflect the combined efforts of the teaching physician and the resident in supporting critical care services.
Notes by the teaching physician must clearly indicate time spent in critical care delivery, the clinical facts relative to the care, and the specific treatment and management provided by the teaching physician. An entry such as “I saw the patient and agree with the resident” is unacceptable. It is expected that the teaching physician’s note provides the details of clinical assessment, time spent and clinical management. A combination of the resident and physician’s documentation must support that critical care was necessary and the time billed was correct. Documentation must be acceptable for billing teaching physician services.
Ventilator management codes (CPT Codes 94002-94004, 94660 and 94662) are not separately payable from other E&M codes, including critical care codes, on the same date of service to the same provider for the same patient. Use of modifier 25 is inappropriate in these circumstances.
Under Revision - Transmittal 1047 Revisions of Sections 30.6.1(B), 30.6.12, and 30.6.13(H) of Chapter 12 of the Medicare Claims Policy Manual
Last Updated Tue, 25 May 2021 19:51:24 +0000