Medicare updates its policy for these services to align with CPT®.
The Centers for Medicare & Medicaid Services (CMS) revised its Part B benefit policy for critical care services, effective Jan. 1, 2022. Policy changes finalized in the 2022 Medicare Physician Fee Schedule (MPFS) final rule include a new definition of critical care services, who can provide critical care services in various settings, and what is included in critical care services and not separately payable. Make sure you’re aware of the changes to ensure proper claims payment for these services.
Critical Care Defined
In the 2022 MPFS final rule, CMS adopted CPT® prefatory language as the definition of critical care visits. CPT® defines critical care as:
… 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.
As in the CPT® code book, CMS finalized for 2022 that critical care services may be reported by a physician or nonphysician practitioner (NPP) who is a QHP. CMS says a QHP is “an individual who is qualified by education, training, licensure/regulation (when applicable), facility privileging (when applicable),” working within their scope of practice.
Reporting Critical Care: Do’s and Don’ts
In the 2022 MPFS final rule, CMS finalized the use of CPT® codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) to report critical care services.
These codes report the total duration of critical care time (continuous or aggregated) provided by the physician or other QHP for a given date of service. Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time.
What if continuous care spans two dates?
The 2022 MPFS final rule finalizes the following language from the CPT® code book regarding when a critical care service furnished by a physician or other QHP extends beyond midnight the following calendar date:
Some services measured in units other than days extend across calendar dates. When this occurs, a continuous service does not reset and create a new first hour. However, any disruption in the service does create a new initial service.
For example, if intravenous hydration (96360, 96361) is given from 11:00 p.m. to 2:00 a.m., 96360 (31 minutes to 1 hour) would be reported once and 96361 (each additional hour) twice.
What if critical care visits are furnished concurrently by different specialties?
care may be furnished as concurrent care to the same patient on the same date by more than one practitioner in more than one specialty, regardless of group affiliation, as long as the services meet the definition of critical care and are not duplicative of other services.
CMS states in the 2022 MPFS final rule, “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.”
What if critical care is furnished concurrently by same specialty and same group?
Multiple practitioners in the same specialty or group can furnish critical care services concurrently to a patient on a single day. Report 99291 when critical care is furnished concurrently by two or more practitioners in the same specialty or group to the same patient on the same date of service, the individual physician or NPP providing the initial critical care. Report subsequent critical care using 99292.
When one practitioner begins the medically necessary initial critical care but does not meet the time requirement to report 99291 (first 30-74 minutes), another practitioner in the same specialty or group can continue to deliver the medically necessary critical care to the same patient on the same day. The total time spent by the practitioners is totaled to meet the time required to report the 99291. Do not report 99292 until an additional 30 minutes of critical care time are furnished to the same patient on the same day.
Services Included in Critical Care
CPT® 2022 also added prefatory language that bundles several services into critical care services, making them not separately payable when furnished concurrently with critical care. Bundled services include:
- Interpretation of cardiac output measurements (93561, 93562)
- Chest X-rays (71045, 71046)
- Pulse oximetry (94760-94762)
- Blood gases and collection and interpretation of physiologic data (e.g., ECGs, blood pressures, hematologic data)
- Gastric intubation (43752, 43753)
- Temporary transcutaneous pacing (92953)
- Ventilator management (94002-94004, 94660, 94662)
- Vascular access procedures
All services need to be sufficiently documented to determine the role each practitioner plays in the treatment of the patient’s care.
Split/Shared Critical Care Visits
Prior to 2022, we could not bill critical care services as split/shared evaluation and management (E/M) services. That has changed, effective for dates of service on or after Jan. 1, 2022. The practitioner who furnishes the substantive portion of the total critical care time may now bill for the service. CMS defines “substantive” as “more than half the cumulative total time in qualifying activities that are included in CPT codes 99291 and 99292.”
For split/shared critical care services, when two or more practitioners spend time jointly with or discussing the patient, that total time may be counted only once.
Append new modifier FS Split (or shared) evaluation and management visit to the codes for shared/split services between a physician and NPP.
Critical Care and E/M
CMS now allows payment for both critical care and E/M visits by the same practitioner(s) in the same specialty or group as long as the practitioner documents that the hospital E/M service was provided at a time when the patient did not require critical care and the service was separate and distinct from any critical care services provided later that date. Append modifier 25 Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service to the claim when reporting these critical care services.
Critical Care Visits and Global Surgeries
Critical care services may be paid separately in addition to a procedure with a global surgical period as long 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 surgical procedure performed (such as trauma or burn cases). Make sure the physician’s note fully documents the separate and distinct nature of the critical care service.
Critical care services should be billed with modifier 24 Unrelated evaluation and management (E/M) service performed by the same physician during the postoperative period and modifier FT Unrelated evaluation and management (E/M) visit during a postoperative period, or on the same day as a procedure or another E/M visit to identify that the critical care was unrelated to the procedure. Note that modifier FT is effective Jan. 1, 2022, and is mandatory on claims as of March 1, 2022.
A modifier is not needed when critical care is performed in the postoperative period by a provider other than the surgeon. However, CMS states in the final rule, “If care is fully transferred from the surgeon to an intensives (and the critical care is unrelated), modifiers 54 Surgical care only and 55 Postoperative management only must also be reported.”
Current Knowledge Is Critical
The policy changes finalized in the 2022 MPFS final rule provide clarity to practitioners on the use of critical care services. Make sure you are evaluating your billing processes, the use of the new modifiers, and any documentation gaps so your providers are educated on the latest Medicare payment policies for critical care.
For More Information: https://www.aapc.com/blog/85270-coding-critical-care-in-2022/