Common Confusing Issues When Reporting Critical Care

Reporting adult critical care can be tricky not only because of the coding but also because of the rules and regulations that go with it. Many questions arise when reporting critical care services in addition to other hospital services. You would think it would be fairly easy since there are only two codes for adult critical care—99291 for the first 30 to 74 minutes and 99292 for each additional 30 minutes in a calendar day. But questions repeatedly arise as to when a practitioner is practicing critical care.

1.How is critical care defined?
2. How do we document time?
3. What are the rules for teaching physicians and billing for critical care?
4. Do I need a modifier when performing a bedside procedure the same day I provide critical care to a patient? What modifier should I use?

​Critical Care Defined
According to the American Medical Association (AMA) Current Procedural Terminology (CPT) 2017, “Critical care is the direct delivery by a physician(s) or other qualified health care professional 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. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.”¹

Critical care must be medically necessary and reasonable, according to the Centers for Medicare and Medicaid Services (CMS). But what does that mean to the practitioner? When a patient has the potential for further deterioration, is that critical care? What about the patient who is on a ventilator but is stable? Does this qualify as critical care? According to CMS Publication 100-4, chapter 12, critical care is defined as service that encompass both treatment of “vital organ failure” and “prevention of further life threatening deterioration of the patient’s condition.”² A patient whom a clinician is providing chronic ventilator management may not be considered critical unless the patient meets the critical care definition even if the patient is being managed in the critical care unit. A patient who had surgery and is placed in critical care for constant observation might not meet the definition if there is no potential for life-threatening deterioration. So, understanding what constitutes critical care is vital in reporting the services accurately. Examples that meet the criteria for critical care are:

• Central nervous system failure
• Circulatory failure
• Shock
• Renal, hepatic, metabolic, and/or respiratory failure

A p​atient on dialysis or hemodialysis is not considered critical unless the patient’s condition is more than longterm management of dialysis dependence.

Time
Critical care is time-based. Code 99291 is reported for the first 30 to 74 minutes and 99292 for each additional 30 minutes. If the patient is managed for fewer than 30 minutes in a calendar day, a different evaluation and management (E/M) service is reported, such as the subsequent hospital visit codes 99231-99233, based on the key components documented. Typically the practitioner reports either 99232 or 99233. Questions always asked are, “How do you document the time? Do you use start and stop times or just total time per calendar date? According to AMA CPT 2017 and CMS Publication 10-4, chapter 12, section 3.6.12, total time per day must be documented. Does that mean in-and-out time or is it sufficient to document total time per patient visit and then total the time for the day?

Even though many consultants recommend documenting start and stop times along with total time to ensure clarity, there is no specific CMS rule that you must document start and stop times for critical care. CMS states in Publication 100-4, chapter 12, “Time counted towards critical care services may be continuous or intermittent and aggregated in time increments spread over a calendar date.” So the answer is that start and stop times are not necessary in reporting critical care for Medicare patients. However, you should carve out the time spent performing procedures or services not included in critical care and make certain that the documentation reflects that the time was not counted, as in this example:

• Critical care time: 134 minutes
• Endotracheal intubation time: 16 minutes 
• Total time: 150 minutes

This clearly differentiates the critical care time from the intubation, which is not bundled into critical care and can be reported separately. In order to report critical care time, the physician or nonphysician provider must be immediately available to the patient. This means that, to be able to count the time as critical care, the practitioner cannot be at home talking about the patient with another physician who is in the ICU, cannot see other patients on the floor or in other units of the hospital, cannot be in the office seeing patients. Keep in mind that critical care does not need to be continuous. It can be intermittent and provided at various times during the calendar day. To finish the billing for your critical care patient for the particular date of service, total all time for that date and report it based on total time.

Only one practitioner may bill for critical care during a specific time period even if more than one physician is managing the patient. For example, if a cardiologist is managing a critical care patient from 1:00 p.m. to 2:00 p.m., and a pulmonologist is also managing the patient, only one physician can bill for that time frame. But if the cardiologist is managing the critical care portion from 1:00 p.m. to 2:00 p.m. and the pulmonologist manages the pulmonology aspect from 3:00 p.m. to 4:00 p.m., both practitioners can bill for critical care services as long as they are managing different conditions. The diagnosis plays a significant role in differentiating these separate problems.

Teaching Physicians
This questions comes up quite often in academic settings: As an attending physician in an academic setting, do I need to be present when the resident examines the patient in the ICU? In other words, if I am in another unit and must see the patient later that morning without the resident, is it acceptable to document that I saw the patient and agree with the resident’s documentation, even if we did not physically see the patient together?

The teaching physician guidelines apply to interns, residents, and fellows. Teaching physicians can report critical care services as long as they provide full attention to the patient. The teaching physician and resident must perform all critical care services together in order to report critical care. If the teaching physician is not present, critical care cannot be reported. A combination of the teaching physician’s documentation and the resident’s documentation may be used to support critical care services.

The teaching physician and resident can link their documentation together for the history and assessment, but the teaching physician must document a statement that he/she personally spent time providing critical care services to the patient along with documentation of time, when the teaching physician saw the patient, rationale for the critical care services, and the teaching physician’s medical treatment and plan of care. In addition the teaching physician should append modifier GC (specifying that this service was performed in part by a resident under the direction of a teaching physician) to the critical care codes reported on the claim.

Performing Bedside Procedures the Same Day as Critical Care
When performing bedside procedures on the same day as critical care, make certain that the procedure is not included in the time reported for critical care. For example, if you are placing a Swan-Ganz catheter (93503), which is not included in critical care, it can be reported separately. In order to get paid for the procedure, you must report the critical care service with modifier 25 to alert the payer that the E/M service is significantly and separately identifiable from the procedure. Here is an example of how to report the services. Total time of critical care services 105 minutes:

• 99291-25 (30-74 minutes) 
• 99292-25 (each additional 30 minutes) 
• 93503 (insertion and placement of flow-directed catheter (e.g., Swan-Ganz) for monitoring purposes

Keep in mind, however, that if the procedure is included in critical care services such as gastric intubation (42752 or 42752), count the time while performing the procedures in your critical care time but do not report the procedure separately because it is bundled into critical care. You can find the services that are bundled into critical care in the AMA CPT 2017, Professional Edition, pages 23-25.¹ 

References
1. American Medical Association. Current Procedural Terminology. Professional Edition. Chicago, IL: American Medical Association; 2017.
2. Centers for Medicare and Medicaid Services. Internet-Only Manual. Publication 100-4. Chapter 12. Section 30.6.12. Washington, DC: Centers for Medicare and Medicaid Services; 2017. https://www.cms.gov/Regulations-and-guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed October 5, 2017.