Be on the Lookout for New Critical Care Service Policies
By Selena Chavis
For The Record
Vol. 34 No. 2 P. 14
Experts dig into the details, potential risk areas, and the importance of readiness.
The 2022 Final Medicare Physician Fee Schedule is now public and brings with it notable changes to the split/shared and critical care rules for 2023. HIM professionals will want to take a closer look at these changes, which impact all settings—office, outpatient, and inpatient—and could potentially have operational and financial impact.
At a high level, Betsy Rios, CPC, pro coding and revenue cycle manager with Healthcare Coding and Consulting Services, says that the Final Rule allows critical care services to be reported when furnished as split (or shared) services.
“In short, the Centers for Medicare & Medicaid Services [CMS] has finalized that the total critical care service time provided by a physician and QHP [qualified health care professional] in the same group on the same day can be aggregated, with the practitioner who furnishes more than half of the total critical care time reporting the critical care services,” she says.
“Critical care is defined as the direct delivery 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,” says Deanna Upston, CCS, CPMA, COSC, CPC, senior coding quality auditor with the Haugen Consulting group.
According to Paul Wojnar, CPC, CPCO, CRC, CEMC, coding compliance officer with Nym Health, the following are the key points to keep in mind when it comes to critical care:
• Critical care services continue to be defined in the CPT Codebook prefatory language for the code set along with the listing of bundled services that are not separately payable.
• Medically necessary critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing different specialties.
• Critical care services can now be furnished as split/shared services, including the following, which should be amended with modifier FS:
- billing based on cumulative time spent and documented by both practitioners; and
- service billed by a physician or advanced practice provider (APP) who spent and documented the greater component of total service time.
• Critical care services billed within the global period of a procedure are allowed if documentation clearly indicates that the critical care is unrelated to the procedure within the global period. In these circumstances, critical care services may be billed with modifiers 24 and FT. FT is a new modifier created by CMS to track critical care services performed within the global period of a procedure that are unrelated to the procedure.
• Beginning on January 1, physician assistants (PAs) have been permitted to bill Medicare directly for their professional services, reassign payment for their professional services, and incorporate with other PAs to bill Medicare for PA services.
• Critical care services rendered on the same day as other evaluation and management visits by the same practitioner or another practitioner in the same group of the same specialty will be paid if the practitioner documents that the evaluation and management visit was provided prior to the critical care service at a time when the patient did not require critical care.
- The visit must be medically necessary.
- These services are required to be separate and distinct with no duplicate elements within the critical care service.
Fortunately, HIM departments can breathe a sigh of relief and proactively address readiness, as the changes—with the one exception—won’t take effect this year, Upston notes.
Prepping Coding and CDI
Proactively addressing the changes now will lay the best foundation for minimal negative impact. Rios suggests that coders become vigilant in looking for proper documentation. “The documentation should clearly show which provider performed more than half of the time to be eligible to bill under the correct provider,” she explains. “We know new rules are something we all must become familiar with—both providers in a split/shared encounter will have to become accustomed to clearly documenting the amount of time he or she spent on critical care. CDI specialists will need to query for missing time documentation.”
Upston adds that the new rules regarding split/shared and critical care as concurrent care will require CDI and coding to work closely with providers to ensure they understand the rules. “Facilities should incorporate these new guidelines into their compliance plan and be clear about what documentation should look like if providers want to bill according to the new rules,” she says.
Many of these changes underline ongoing efforts to achieve compliant and comprehensive attestations for time and modalities performed outside of bundled procedures, Wojnar says, noting that in addition to these efforts, it is important that shared documentation clearly indicates time that is not concurrent between APPs and physicians when reporting split/shared critical care time.
Going forward, coding and CDI can expect that the new modifier FS will prove tricky. Required on claims to identify split/shared visits and to help ensure program integrity, Rios says that documentation in the medical record must identify not only the two individuals who performed the visit but also the individual who provided more than half of the time. Whoever that is must sign and date the medical record.
Wojnar notes that making sure that nonbundled procedure time is carved out from the separately billable critical care time—if that procedure is separately captured and time is documented—will continue to be a source of consternation. “It is not always enough to take statements indicating that the critical care time is separate from billable procedures,” he explains. “If most of the critical care time was spent on a billable procedure, the provider cannot bill both. Coding professionals must also make sure that concurrent time is not aggregated between APPs and physicians.”
Rules for Critical Care Services Furnished by a Single Physician or Nonphysician Practitioner
Upston points out that these rules have not changed. In order for a single physician or nonphysician practitioner to furnish critical care, they must document medical necessity, must be immediately available to the patient, and should state how much time they spent in critical care.
Digging deeper, Rios notes that for critical care services furnished by a single physician or QHP, CMS has adopted the rule that CPT code 99291 should be used to report the first 30 to 74 minutes of critical care services rendered on a given date. CPT code 99292 should be used for additional 30-minute time increments provided to the same patient.
“CPT codes 99291 and 99292 will be used to report the total duration of time spent by the physician or QHP providing critical care services to a critically ill or critically injured patient, even if the time spent by the practitioner on that date is not continuous,” she says. “Noncontinuous time for medically necessary critical care services may be combined.”
Rules for Critical Care Services Furnished as Concurrent Care
Under the new rules, Wojnar says that medically necessary critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing different specialties. Concurrent critical care time cannot be aggregated for split/shared services.
According to Upton, this represents a substantial change to the previous guidelines, which stated only one provider may be reimbursed for critical care during the same time period. “The key here is ‘when medically necessary’ and has always applied when billing concurrent care,” she says. “When multiple providers are seeing the patient and billing for their services on the same date, CMS is going to want to see clear documentation that their services were not duplicative.”
For example, it would be difficult to defend medical necessity for both a hospitalist and a pulmonologist billing critical care for the same time period with the same diagnosis code of acute hypoxic respiratory failure.
Rules Governing Split/Shared Services
Upston says the big change here is that CMS has ruled that the service may be billed by the practitioner who performed the substantive portion of the visit. It does not clarify that the substantive portion must be face to face.
Billing is now based on cumulative time spent and documented by both practitioners (not simultaneous), Wojnar reiterates. Services are billed by the physician or APP who spent and documented the greater component of total service time.
For example: A certified registered nurse practitioner (CRNP) and a physician separately spend 30 (physician) and 20 (CRNP) minutes for a total of 50 minutes. In addition, they spend 15 minutes discussing the patient, which adds 15—not 30—minutes to the formula.
The total is 65 minutes. The physician can report 65 minutes: 20 minutes from the CRNP, his 30 minutes with the patient, and his 15 minutes discussing the patient with the CRNP.
Documentation Requirements for Critical Care Services
The documentation requirements for critical care services largely have not changed, Upston says. “Medical necessity is always the overarching criteria for CMS to reimburse for any service. The service must meet the definition of critical care,” she says. “Providers need to document how much time they spent performing critical care, with details on specific intervention done to support or prevent vital organ systems from failure. The provider must be immediately available to the patient. Additionally, if the provider performs any procedures that may be separately billed, they should be sure to exclude that time from their total critical care time. Documentation should include that information.”
“The duration of critical care services to be reported is the time the physician spent evaluating, providing care, and managing the critically ill or injured patient’s care,” Rios explains. “That time must be spent at the immediate bedside or elsewhere on the floor or unit so long as the physician is immediately available to the patient.”
For example, time spent reviewing test results or discussing the critically ill patient’s care with other medical staff in the unit or at the nursing station on the floor may be reported as critical care. Rios adds that physicians must devote their full attention to the patient and, therefore, cannot provide services to any other patient during the same time period. For each date and encounter entry, the physician’s progress note should document the total time that critical care services were provided.
In the case of procedures performed that are not bundled into critical care (ie, billed and paid separately), Rios says that time may not be included and counted toward critical care time. “The physician’s progress note in the medical record should document that time involved in the performance of separately billable procedures was not counted toward critical care time,” she points out.
Finally, Rios notes that time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options (as described in CPT), may be counted toward critical care time when specific criteria are met.
In a nutshell, Wojnar says that documentation of critical care must include the following criteria:
• It must demonstrate the severity of illness, the intensity of services required to treat the illness, and the time spent in providing the care.
• It must show the medical necessity for providing critical care services.
• Typically, a critical care service is provided to a patient in a “critical care area” such as the coronary care unit, ICU, respiratory care unit, or the emergency department. While critical care could be rendered in other locations, it is uncommon to see this service occurring regularly in other areas.
— Selena Chavis is a Florida-based health care writer.