Podcast Episode 5: Critical Care Coding
Episode Summary: Critical Care coding is complicated. There are clearly defined requirements that must be adhered to in order to bill this time-based service. Hosts Neal Sheth and Dr. Piyush Sheth explore the intricacies involved with Critical Care coding.
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Hosts: Neal Sheth, CGSC; Piyush Sheth, MD, FACS, DABS, CGSC
NEAL SHETH: How can the complexities of medical coding be simplified? Can healthcare providers and professional medical coders maintain efficiency in an environment of ever-increasing complexity?
This is Unraveling Medical Coding and I’m your host and Certified General Surgery Coder, Neal Sheth.
PIYUSH SHETH: And I’m Dr. Piyush Sheth, a General Surgeon and author of Coding Solutions, General Surgery and Starting Medical Practice.
NEAL: Hi dad.
PIYUSH: Hey Neal. Today let’s talk about Critical Care services since the guidelines for billing Critical care services are quite complex and are not often fully understood. I just want to mention to our audience that this is an extremely dense episode so if you have to go back or you want to see something in writing, please look at the script that’s on our website.
NEAL: Let’s get into it. Let’s have a go at trying to sort out this complexity.
PIYUSH: So, let’s start with some basics.
The first requirement for billing Critical Care services is that the service must be provided to a critically ill or injured patient and must be reasonable and medically necessary. There is no stipulation regarding place of service. The patient does not necessarily have to be in the ER or Intensive Care Unit.
Second, a critical illness or injury is defined as one that acutely impairs vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition. Therefore, services provided must treat the vital organ failure and prevent further life-threatening deterioration of the patient’s condition. This usually involves high complexity decision making to assess, manipulate, and support vital functions or to prevent further life-threatening deterioration of the patient’s condition, and typically involves interpretation of physiologic parameters and use of advanced technology.
NEAL: Can you give us some examples of services that may seem at first glance to qualify as Critical care services but actually do not?
PIYUSH: I’ve got 4 examples that bring the point home.
Example 1: You are managing a patient for daily ventilatory management or a patient who is on chronic dialysis who is in the ICU. Since these are chronic illnesses, they do not meet the criteria for a critical illness or injury and would not qualify as Critical care services.
Example 2: You are managing a patient who was admitted to the ICU because the hospital had no other beds available for that patient. Again, unless the patient has a critical illness or injury that meets criteria, this would not qualify as Critical care services. Just being in the ICU in and of itself does not allow you to bill Critical care services.
Example 3: You are managing a patient who is on an insulin drip for diabetes in the ICU. Your hospital policy states that all insulin drips must be managed in the ICU. This would not qualify for Critical care service billing since the only reason the patient is in the ICU is due to a hospital policy and not because he meets critical illness or injury criteria.
Lastly, Example 4: Your hospital has a policy that all ICU patients are to be seen by an Intensivist or Hospitalist. Again, just being in the ICU does not qualify for Critical care service billing unless critical illness or injury criteria have been met.
NEAL: So, let’s say a service is medically necessary, reasonable, and meets critical illness or injury criteria. Are there any other requirements to bill for Critical Care services?
PIYUSH: Yes. Critical Care service billing is time based. Total time of less than 30 minutes should be billed using non-critical care CPT codes. To use the initial critical care service CPT code 99291, a minimum of 30 minutes total time must be documented. The total time may be contiguous or may be intermittent and then aggregated.
During the time period claimed, only one provider can bill for critical care services. For example, if a Trauma surgeon and an Intensivist both manage a critically ill patient from 8 AM to 9 AM, only one provider is allowed to bill critical care services during that time period. Also, a provider may not provide services to any other patient during that time period but must provide full attention to the critically ill patient. Therefore, critical care services cannot be shared / split services between a physician and a non-physician provider or NPP. I’ll repeat that because it is an important point. Critical Care services cannot be shared / split services between a physician and an NPP.
However, when a physician or NPP provides coverage for patients, the first hour of critical care services, CPT code 99291, must be provided by the same provider before subsequent critical care services can be billed by covering providers using the add-on additional 30-minute incremental critical care CPT code 99292.
The provider time must be spent devoting full attention to the patient at the bedside or elsewhere on the floor or unit as long as the physician is immediately available in time of crisis. Time spent in activities off the unit or floor (ie., telephone calls, going to radiology to review X-rays, etc.) cannot be counted because the physician is not immediately available for patient management.
Time spent obtaining history and information from the patient’s family or surrogates can be used in the critical care time calculation provided there is clear documentation.
Time spent teaching cannot be counted and neither can time spent by a resident when the teaching physician is not present. For resident time to be counted, the teaching physician must also be present at the bedside during that entire time and the documentation must clearly state the time the teaching physician spent.
NEAL: Are there certain procedures that are bundled with the total time calculation?
PIYUSH: Yes, there is a whole list of procedures that cannot be billed separately from Critical Care services. These include:
Interpretation of cardiac output measurements
Blood draw for specimen
Nasogastric intubation
Pulse oximetry
Chest X-rays, professional component
Blood gases, and information stored in computers like EKG, blood pressure, and hematologic data
Temporary transcutaneous pacing
Ventilatory management
And starting peripheral IV’s
NEAL: So what procedures would not be included in calculating total time and therefore could be billed separately?
PIYUSH: Procedures such as endotracheal intubation, bronchoscopy, cardioversion, chest tube insertion, or central line insertion can be billed separately and should not be included in the critical care service time calculation. The documentation must clearly state that “the time involved in performance of separately billed procedures was not counted towards critical care time.”
NEAL: Are there other scenarios that point to pitfalls in billing?
PIYUSH: Of course, there are special situations that we need to keep in mind.
Medicare prohibits billing an ED visit and a critical care service on the same day, by the same physician.
Critical care services can be billed on the same day as a surgical procedure using modifier 25 to indicate that the critical care is a significant separately identifiable service that is above and beyond the usual pre- and post- operative care associated with the procedure performed. Obviously proper documentation is a must in this situation.
Critical care services can be billed during the post-operative global surgical period using modifier 24 if there is documentation that clearly identifies that the critical care was unrelated to the anatomic injury or surgical procedure performed.
If a service is provided for a hospital inpatient or office/outpatient and later that day the patient’s condition deteriorates and critical care services are provided, both the critical care service and the previous hospital or office service can be billed.
Physicians in the same group practice of the same specialty should not each report an initial critical care CPT code 99291 on the same date of service.
NEAL: Wow, confusing is a mild understatement. So, can you summarize Critical Care services for us?
PIYUSH: Sure. A service provided to a patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet specific requirements. The provider must devote his full attention to the care of that patient and be immediately available at bedside or on the unit. Because critical care services are time based, knowing what activities are bundled and not bundled with the time calculation is important. And lastly, proper documentation is the foundation for proper billing code selection.
NEAL: Thanks, dad, for clarifying Critical Care coding.
PIYUSH: My pleasure.
NEAL: We hope you enjoyed this episode of Unraveling Medical Coding. Don’t forget to subscribe to Unraveling Medical Coding from wherever you get your podcasts. Also, we would love to hear your thoughts, so please leave us a review on Apple podcasts. Stay safe, and stay healthy.