by Raquel Shumway
February 11th, 2022
Medicare’s policy for billing critical care services was included in the Medicare Claims Processing Manual, Section 30.6.12. These provisions were withdrawn on May 9, 2021. Further information on this action can be found in this CMS Notice: https://www.cms.gov/files/document/enf-instruction-split-shared-critical-care-052521-final.pdf .
Medicare’s 2022 Medicare Physician Fee Schedule Final Rule (MPFS) included updates to their policies regarding Critical Care Services (CCS) bringing them more into alignment with the guidelines found in the CPT 2021® Professional Codebook (hereafter, CPT Codebook). Medicare stated that they will review and revisit these guidelines as changes are made to the guidelines contained in the CodeBook. The Complete Ruling can be found at: https://public-inspection.federalregister.gov/2021-23972.pdf
Note: This article only discusses the changes in the MPFS Final Rule. For more information about reporting these services, see the article “Will Your Critical Care Services Pass An Audit?”
Definitions Accepted by Medicare in the Final Rule
The MPFS included definitions for “Critical Care Services” and the qualifications of a physician or QHP/NPP in relation to these services.
Critical Care Services:
Medicare has accepted the prefatory language contained in the CPT Codebook for the definition of critical care services. You can find further clarification on page 31-33 of the 2022 CPT Codebook (also available with a FindACode.com subscription).
|The CPT prefatory language states that critical care 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.
Centers for Medicare & Medicaid Services (CMS), Health and Human Services (HHS) Final Rule
Physician or QHP/NPP
In accordance with the definition above, critical care services can be performed by a physician or QHP. Medicare has ruled that “critical care services may be reported by a physician or NPP who is a Q HP (as explained above).” In the final rule medicare refers to such an individual as a non-physician provider or NPP.
Included in the Final Rule for Critical Care Services
Besides the changes in definitions above, the final rule included information on the following:
- Critical Care Services 99291–99292
- CCS & Bundled Services
- CCS & Time spent in critical care including what happens when it crosses the midnight hour
- CCS & Concurrent Visits
- Same-Day Emergency Department, Inpatient or Office/Outpatient Visits
- CCS — Split or shared visits
- CCS & Global Surgery
- Medical Record Documentation Requirements
Per the Medicare Final Rule: “Critical care visits are described by CPT codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (each additional 30 minutes (List separately in addition to code for primary service).”
These CCS codes are used to report the total time taken to provide critical care. The CPT Codebook further states that the physician or QHP/NPP “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.”
Medicare has adopted the following services listed in the CPT Codebook as “included in critical care when performed during the critical period by the physician(s) providing critical care.”
- Interpretation of cardiac output measurements
- Chest X rays (71045, 71046)
- Pulse oximetry (94760, 94761, 94762)
- Blood gases, and collection and interpretation of physiologic data (e.g., ECGs, blood pressures, hematologic data); gastric intubation (43752, 43753)
- Temporary transcutaneous pacing (92953)
- Ventilatory management (94002–94004, 94660, 94662)
- Vascular access procedures (36000, 36410, 36415, 36591, 36600)
|Per the CPT Codebook: “Any services performed that are not listed above should be reported separately. Facilities may report the above services separately.
CPT Coding Guideline, Critical Care
Time Spent Performing CCS Services
As stated earlier, codes 99291 and 99292 are used to report the total duration of time spent. Whether it is continuous or non-continuous, it must be aggregated, and must be 100% devoted to the critically ill/injured patient. The time cannot be counted if the time was spent with any other patient during the same time.
Tip: Appropriately documenting time is essential to avoid double-reporting.
According to the CPT Codebook prefatory language, which has been accepted by Medicare, “Time spent with the individual patient should be recorded in the patient’s record. The time that can be reported as critical care is the time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit.” The following table summarizes these activities.
Critical Care Services Qualifying Time/Activities
Time cannot be counted if spent with any other patient during the same time
Time spent with patient
Time spent in activities outside the unit or off the floor
NOTE: Time spent on excluded activities are not reported as critical care time.
Time spent with family or decision makers
must have direct bearing on care & management of the patient)
The actual reporting of the time may vary depending on the circumstances in which the critical care services are provided (see concurrent services below). However, the general rule for reporting and documenting is:
|the physician or NPP would report CPT code 99291 for the first 30-74 minutes of critical care services provided to a patient on a given date. The CPT Codebook indicates that CPT code 99291 should be used only once per date even if the time spent by the practitioner is not continuous on that date. Thereafter, the physician or NPP would report CPT code 99292 for additional 30-minute time increments provided to the same patient.
Centers for Medicare & Medicaid Services (CMS), Health and Human Services (HHS) Final Rule
Note: According to CMS, “code 99291 should be used only once per date even if time spent by the practitioner is not continuous on that date.”
Crossing the midnight hour
Medicare is adopting the following rule contained in the CPT Codebook to report instances when service extends from one day to the next:
|Some services measured in units other than days extend across calendar dates. When this occurs, a continuous service does not reset and create a first hour. However, any disruption in the service does create a new initial service. For example, if intravenous hydration (96360, 96361) is given from 11 pm to 2 am, 96360 would be reported once and 96361 twice. For continuous services that last beyond midnight (that is, over a range of dates), report the total units of time provided continuously.
CPT Codebook, page xvii
Critical Care & Concurrent Services
Medicare policy states that “concurrent care exists where more than one physician renders services more extensive than consultative services during a period of time. The reasonable and necessary services of each physician rendering concurrent care could be covered where each is required to play an active role in the patient’s treatment (for example, because of the existence of more than one medical condition requiring diverse specialized medical services).”
The final rule also states “critical care visits may be furnished as concurrent care (or concurrently) to the same patient on the same date by more than one practitioner in more than one specialty (for example, an internist and a surgeon, allergist and a cardiologist, neurosurgeon and NPP), regardless of group affiliation, if the service meets the definition of critical care and is not duplicative of other services.”
Remember that, as always, the services still need to be medically reasonable and necessary.
Critical Care Services & Split/Shared Services
Reporting Critical Care and Concurrent Services Rendered
Split or Shared CCS Services — To Same Patient on the Same Date
|CCS furnished by 2 or more practitioners or NPPs||
Aggregated time (summed)
Report AFTER initial 104 min met
|Same Specialty||Same group** (Follow up care)||
one or more units
Practitioner furnishing substantive portion*** of cumulative CCS time
*This is the new split (or shared) visit modifier.
New Modifier -FS Split or shared e/m visit (Critical Care services which are split shared)
**Same group is not being defined at this point. Data will be monitored for future rulemaking.
***Substantive portion refers to more than half of the total time spent by a physician or NPP performing the split (or shared) visit.
Note: Medicare policy concurs with the CPT codebook E/M guidelines which states “for split (or shared) visits, when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted.”
Critical Care Services & Same-Day ER, Inpatient or Office/Outpatient E/M Visitis
Due to the fact that concerns were expressed about duplicating payment for services performed on the same day as critical care services, the general rule is that “no other E/M visit can be billed for the same patient on the same day as a critical care services when services are furnished by the same practitioner, or by practitioners in the same specialty in the same group.” However, there are some exceptions to the general rule.
The following circumstances and requirements will allow a physician/NPP/QHP to bill for both an E/M service and a critical care service provided on the same date. Reporting these critical care services requires the use of the modifier -25.
- Documentation shows the E/M visit(s)/service(s):
- was provided prior to the Critical Care Service but CCS is subsequently required
- was for unrelated problems and could not be provided during the same encounter
- E/M was provided at a time when patient did not require critical care (e.g., before the situation became critical)
- E/M service is medically necessary
- E/M service is separate and distinct
- No duplicative elements from the critical care service were provided later in the day
Note: See CMS Fact Sheet “Calendar Year (CY) 2022 Medicare Physician Fee Schedule Final Rule” for further information on these critical care services and the modifier -25.
Note: See also, the note included within the description of modifier -25 in the CPT Codebook, “Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.”
Critical Care Services & Global Surgery
The Final Rule did not change any of their previously published policies regarding CCS and global surgery. They stated that they may, in the future, consider a Multiple Procedure Payment Reduction (MPPR) to identify critical care that is billed in conjunction with a global surgical procedure which would discount one of the services. But for now, they are keeping the current policy, which states that critical care services “may be separately paid in addition to a procedure with a global surgical period, as long as the critical care service is unrelated to the procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (for example, trauma, burn cases).”
The following modifiers are associated with the reporting of critical care services. Medicare has created the new modifier -FT which will be required on this type of claim as of January 1, 2022 in order to identify that the critical care is unrelated to the global procedure and that the critical care “is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (for example, trauma, burn cases).
Modifier -54 surgical care only
Modifier -55 postoperative management only
Modifier -FT Separate, unrelated e/m (Critical Care services unrelated to the global surgery)
The following example (taken from the Final Rule) provides additional information. The new “yet to be identified” modifier is modifier FT:
|Care is fully transferred from a surgeon to an intensivist. Critical care is unrelated.
The surgeon reports modifier -54.
The intensivist, who accepts the transfer of care reports both modifier -55 and the new, unrelated modifier (yet to be identified).
Note: Documentation must clearly support that the work of both critical care and global surgery were performed.
Medical Record Documentation Requirements
Medical record documentation is important especially for split or shared billing. Medicare states “in order to support coverage and payment determinations regarding split (or shared) critical care services, documentation requirements for all split (or shared) E/M visits would apply to critical care visits also.”
Following are documentation requirements given by Medicare in the final ruling.
- Total time of each practitioner (not necessarily start and stop times)
It could be helpful for each practitioner who provided the split (or shared) visit to document their time in the medical record. However, medicare is leaving it to the practitioner(s) and group(s) to determine how to track individual time in order to determine who performed the substantive portion.
- Name of practitioners, if it is a split (or shared) visit
- Individual performing substantive portion bills the service
- signs and
- dates the medical record
- Include concurrent care
- Services are reasonable and necessary for:
- Diagnosis or treatment of illness or injury
- Improvement of function of a malformed body member
- To support coverage and determinations regarding concurrent care. This means sufficient documentation to allow a medical reviewer to determine the role each practitioner played in the patient’s care.
- Condition or conditions for which patient was treated
- Include practitioner
Be sure to review your current documentation and billing practices regarding the changes in the 2022 MPFS Final Rule. Remember also, to bring your policies and procedures and bring your staff up to date.
Summary of Policies in the Calendar Year (CY) 2022 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List