Critical care in 2023

Q:What are the changes to critical care services for 2023?

A:Medicare’s guidelines now align with the CPT’s definition of critical care, which is, “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.”Additionally, critical care 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.

Critical care services can be provided by physicians and non-physician practitioners (NPP’s), including nurse practitioners (NP’s), physician assistants (PA’s), certified nurse specialists (CNS’s) and certified nurse midwives (CNM’s). Medicare recognizes that PA’s can bill directly under their NPI and be paid directly for their personal, professional services, which was not the case prior to January 1, 2022.Make sure each provider is credentialed to perform services in the hospital where they are seeing patients.

The critical care codes are:

99291Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes

99292each additional 30 minutes (list separately in addition to code for primary service)

Critical care may be furnished on multiple days, and is typically furnished in a critical care area, which can include an intensive care unit or emergency department. Critical care requires the full attention of the physician or NPP and therefore, for any given time period spent providing critical care services, the practitioner cannot provide services to any other patient during the same period of time.

These codes can be billed for the aggregate time spent during one date, even if the time is non-continuous. For continuous services that extend beyond midnight, the physician or NPP will report the total units of time provided continuously.However, any disruption in the service creates a new initial service.

In situations where a patient receives another evaluation and management (E/M) visit on the same calendar date as critical care services, both may be billed (regardless of practitioner specialty or group affiliation) as long as the medical record documentation supports the following:

1. The other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care,
2. The services were medically necessary, and
3. The services were separate and distinct, with no duplicative elements from the critical care services provided later in the day.

In these situations, Modifier 25 should be appended to the hospital E/M code.

Physician(s) or NPP(s) in the same specialty and in the same group may provide concurrent follow-up care, such as a critical care visit subsequent to another practitioner’s critical care visit.In the situation where a practitioner furnishes the initial critical care service in its entirety and reports CPT code 99291, any additional practitioner(s) in the same specialty and the same group furnishing care concurrently to the same patient on the same date report their time using the code for subsequent time intervals (CPT code 99292).

When one practitioner begins furnishing the initial critical care service but does not meet the time required to report CPT code 99291, another practitioner in the same specialty and group can continue to deliver critical care to the same patient on the same date.Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported by a practitioner in the same specialty and group when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes).For instance, if Practitioner A spends 15 minutes of critical care, then 99291 cannot be billed, but, if Practitioner B spends 30 minutes of critical care, they can bill 99291 with a total time of 45 minutes as one claim.

Concurrent care is when more than one physician renders services that are more extensive than consultative services. The services of each physician furnishing concurrent care is covered when each plays an active role in the patient’s treatment. In the context of critical care services, a critically ill patient may have more than one medical condition requiring diverse, specialized medical services and requiring more than one practitioner, each having a different specialty, playing an active role in the patient’s treatment.The services for each provider must be:

• medically necessary,
• meet the definition of critical care, and
• not duplicative of other services.

Bundled services that are included by CPT in critical care services and therefore not separately payable include:

• interpretation of cardiac output measurements,

• chest X rays,

• pulse oximetry,

• blood gases and collection and interpretation of physiologic data (for example, ECGs, blood pressures, hematologic data),

• gastric intubation,

• temporary transcutaneous pacing,

• ventilator management, and

• vascular access procedures.

Time spent performing separately reportable procedures or services should be reported separately and should not be included in the time reported as critical care time.

Split/Shared Critical Care Services

Critical care can be billed as a split/shared visit and the provider who reports the service must have performed a substantive portion of the service, which is defined as more than half of the total time spent by the physician and NPP.To bill a split/shared critical care service, the billing practitioner needs to append Modifier FS (to designate a split/shared E/M visit) to the critical care code on the claim. Also, keep in mind that, when two or more providers spend time jointly meeting with or discussing the patient as part of a critical care service, the time can only be counted once.

Source documents:

CMS Transmittal Number R11288CP

IOM Claims Processing Manual, Sections 30.6.18, 30.6.12.7

Renee Dowling is a compliance auditor at Sansum Clinic, LLC, in Santa Barbara, California.