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March 27, 2018


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Medical Coding News Archives

Get Re-Acquainted with Critical Care Billing and Documentation Requirements

 
March 25, 2008:
Medicare has recovered millions of dollars from physicians and nonphysician practitioners (NPP) who incorrectly bill professional Evaluation and Management (E/M) services or bill E/M levels that are not supported by the documentation of the encounter or by the patient`s actual condition. So physicians and NPPs may want to closely review the billing and documentation requirements before billing inpatient hospital visits and critical care services provided on the same day. The Centers for Medicare and Medicaid Services (CMS) recently released Transmittal 1473, Change Request 5792, updating the Medicare Claims Processing manual section 30.6.9 — Payment for Inpatient Hospital Visits (Codes 99221–99239).

CMS advised physicians and NPPs to retain documentation for both hospital care and critical care claims for possible review if the claim is questioned. The documentation must support critical care services for the patient on the same date as inpatient hospital visits or other E/M services by the same physician or, in a group practice, by another physician of the same specialty.

Both Initial Hospital Care codes (99221–99223) and Subsequent Hospital Care codes (99231–99233) may only be reported by a physician once per day for the same patient. Regardless of the number of encounters or whether the problems addressed are related, the physician should report one code that represents all services provided on that date of service. However, when a hospital inpatient (or emergency department or office/outpatient) E/M service is rendered and the patient subsequently requires critical care on the same date of service, both the critical care services (CPT® codes 99291 and 99292) and the E/M service may be paid.

Critical care is not specific to a location such as an ICU or CCU but rather is determined by the patient`s condition requiring direct physician care regardless of the location. Critical care is defined as 30 minutes or more of direct care provided by the physician to a critically ill or injured patient, regardless of the location. All time spent exclusively with patient/family/caregivers in the nursing unit or elsewhere must be recorded in the medical record.

The following services are included in critical care codes 99291 and 99292 when provided during the critical care period:
  • pulse oximetry
  • chest x-rays
  • interpretation of cardiac output measurements
  • blood gases and information data stored in computers (e.g., blood pressures, ECGs, hematologic data)
  • temporary transcutaneous pacing
  • vascular access procedures
  • gastric intubation
  • ventilatory management

According to the transmittal, physicians and NPPs may bill critical care services and inpatient hospital care for the same patient on the same calendar date when the patient did not require critical care during the previous encounter to receiving critical care services. CMS also instructs providers that during critical care management, those services that do not meet the level of critical care should be reported using subsequent hospital visit codes (99231–99233).

CMS has promised “discretionary contractor review” if the claim is questioned, so physicians and NPPs need to be aware of the billing criteria and documentation guidelines for both critical care and E/M services and ensure thorough documentation.

Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS
Clinical Technical Editor

 

 
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