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- Critical Care Services UCDHS Compliance Office CPT Codes 99291 – 99292 Documentation Notice Date Issued: 11/28/05 Date Revised: 10/15/09 99291: Critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes 99292: Critical care, each additional 30 minutes (List separately in addition to code for primary services) Definition Critical care is defined as the direct delivery by a physician(s) 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”. Medical Necessity Critical care services include the treatment of vital organ failure and/or the prevention of further life threatening deterioration in a patient’s condition. Delivering critical care in a moment of crisis, or upon being called to the patient’s bedside emergently, is not the only requirement for providing critical care service. Treatment and management of a patient’s condition in the threat of imminent deterioration while not necessarily emergent, is also required. The presence of a patient in an ICU or CCU, or the patient’s use of a ventilator, is not sufficient to warrant billing critical care services. The service must be medically necessary and meet the definition of critical care. Medically reasonable and necessary services that do not meet all the criteria to report critical care should be reported with the appropriate evaluation and management code (e.g., CPT codes 99231-99233). Critical Care Documentation – Full Attention of Physician Since critical care is a time-based service, the physician’s critical care note(s) must document the total time spent evaluating, managing and providing critical care services to a critically ill or injured patient. Critical care time may be continuous or intermittent in aggregated time increments. Time spent performing separately billable procedures/services cannot be used to support critical care time. The time spent providing critical care services must be spent at the immediate bedside or elsewhere on the floor or unit as long as the physician is immediately available to the patient. Therefore, the physician cannot provide services to any other patient during the same period of time. Teaching Physician In the teaching environment, the teaching physician must be present for the entire period of time for which the claim is submitted. Time spent teaching may not be counted towards critical care time. The teaching physician, in addition, cannot bill for time spent by the resident providing critical care services in their absence. Only time that the teaching physician spends with the patient, or that he/she and the resident spend together with the patient, can be counted toward critical care time. 1
- Critical Care Services UCDHS Compliance Office CPT Codes 99291 – 99292 Documentation Notice Date Issued: 11/28/05 Date Revised: 10/15/09 Provided that all requirements for critical care services are met, the teaching physician’s documentation may tie into the resident's documentation. The teaching physician may refer to the resident’s documentation for specific patient history, physical findings and medical assessment. NOTE: It is the teaching physician’s “stand alone” documentation that determines whether a critical care services can be billed. The teaching physician medical record documentation must provide information including the time the teaching physician spent providing critical care; that the patient was critically ill during the time the teaching physician saw the patient; what made the patient critically ill; and the nature of the treatment and management provided by the teaching physician. The following is an example of acceptable teaching physician documentation: Patient seen and examined with Dr. Resident. Reviewed and agree with his note and the plan of care we developed together. One hour of critical care time personally performed due to patient’s hemo-dynamic instability. Patient was resuscitated with 2 units of packed red blood cells. Additional studies were obtained to determine possible causes for patient’s instabilities. Included Services The following services are inclusive of critical care services and should not be reported separately the interpretation of cardiac output measurements (93561, 93562), chest x-rays (71010, 71015, 71020), blood draw for specimen (36415), blood gases and information data stored in computers (e.g., ECGs, blood pressures, hematologic data) (99090), gastric intubations (43752, 91105), pulse oximetry (94760, 94761, 94762), temporary transcutaneous pacing (92953), ventilator management (94002-94004, 94660, 94662), and vascular access procedures (36000, 36410, 36415, 36591, 36600). Family Counseling/Discussions Routine daily updates to family members are considered part of critical care services and not separately billable. However, time spent with family member or other surrogate decision makers may be counted toward critical care time when these criteria are met: • The patient is unable or clinically incompetent to participate in giving a history and/or decision making and • The discussion is necessary for determining treatment decisions A summary of any family discussion is to be documented within the medical record and should include that the patient was unable or incompetent to participate and the necessity of the discussion and any treatment decisions made. Telephone calls to family members and/or surrogate decision makers may be counted provided that they meet the same criteria as described above. All other family discussions, no matter how lengthy, may not be counted towards critical care time. 2
- Critical Care Services UCDHS Compliance Office CPT Codes 99291 – 99292 Documentation Notice Date Issued: 11/28/05 Date Revised: 10/15/09 Other Coding Requirements • 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/injured patient. • Physicians assigned to a critical care unit (hospitalist/intensivist) may not report critical care based on a “per shift” basis. • Services cannot be reported as a split/shared service when performed by a physician and a qualified NPP of the same group practice. • Physicians in the same group practice, with the same specialty, may not report 99291 for the same patient on the same calendar date. • Concurrent care by more than one physician representative by different specialties is payable if the services meet critical care requirements, (i.e., must be medically necessary and non-duplicative.) • Hospital emergency department services are not payable for the same date as critical care services when provided by the same physician or physicians of the same specialty. • Critical care services will not be paid on the same calendar date that a physician reports an unbundled procedure with a global surgical period, unless the critical care is billed with modifier -25 to indicate a significant, separately identifiable E/M service was performed. Resources 1. AMA/CPT 2009 Critical Care Services 2. CMS Medicare Claims Processing Manual 100-4, Chapter 12, Section 30.6.12 3. UCDHS Teaching Physician Guidelines for Professional Fee Billing #1928 This document is in the opinion of the UCDHS Compliance Office based on the indicated references listed above as of October 15, 2009. Please be advised that regulations and guidelines are often subject to change, therefore, the Compliance Office would like to encourage the reader to follow any changes to the state and federal regulations that may affect this opinion. 3
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