How To Avoid Medicare Denials for Critical-Care Billing
Do not count time associated with periodic condition updates to the family or answering questions about the patient’s condition that are unrelated to decision-making.
Family discussions can take place via phone as long as the physician is calling from the patient’s unit/floor and the conversation involves the same criterion identified for face-to-face family meetings.6
Critically ill patients often require the care of multiple providers.3 Payors implement code logic in their systems that allow reimbursement for 99291 once per day when reported by physicians of the same group and specialty.8 Physicians of different specialties can separately report critical-care hours. Documentation must demonstrate that care is not duplicative of other specialists and does not overlap the same time period of any other physician reporting critical-care services.
Same-specialty physicians (two hospitalists from the same group practice) bill and are paid as one physician. The initial critical-care hour (99291) must be met by a single physician. Medically necessary critical-care time beyond the first hour (99292) may be met individually by the same physician or collectively with another physician from the same group. Cumulative physician time should be reported under one provider number on a single invoice in order to prevent denials from billing 99292 independently (see “Critical-Care Services: Time Reminders,”).
When a physician and a nurse practitioner (NP) see a patient on the same calendar day, critical-care reporting is handled differently. A single unit of critical-care time cannot be split or shared between a physician and a qualified NP. One individual must meet the entire time requirement of the reported service code.
More specifically, the hospitalist must individually meet the criteria for the first critical-care hour before reporting 99291, and the NP must individually meet the criteria for an additional 30 minutes of critical care before reporting 99292. The same is true if the NP provided the initial hour while the hospitalist provided the additional critical-care time.
Payors who recognize NPs as independent billing providers (e.g. Medicare and Aetna) require a “split” invoice: an invoice for 99291 with the hospitalist NPI and an invoice for 99292 with the NP’s NPI.9 This ensures reimbursement-rate accuracy, as the physician receives 100% of the allowable rate while the NP receives 85%. If the 99292 invoice is denied due to the payor’s system edits disallowing separate invoicing of add-on codes, appeal with documentation by both the hospitalist and NP to identify the circumstances and reclaim payment.
Critical-Care Services: Time Reminders
Two available codes:
99291: Critical care, evaluation and management of the critically ill or critically injured patient: first 30-74 minutes. It is reported only once per day, per physician or group member of the same specialty.
+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). Categorized as an “add on” code, it must be reported on the same invoice as its “primary” code, 99291. Multiple units of code 99292 can be reported per day per physician/group (see Table 1).
Critical-care time constitutes bedside time and time spent on the patient’s unit/floor where the physician is immediately available to the patient. Also count physician time associated with the performance and/or interpretation of labs, diagnostic studies, and procedures inherent to the provision of critical care:
- Cardiac output measurements (93561, 93562);
- Chest X-rays (71010, 71015, 71020);
- Pulse oximetry (94760, 94761, 94762);
- Blood gases and interpretation of data stored in computers (e.g. ECGs, blood pressures, hematologic data [99090]);
- Gastric intubation (43752, 91105);
- Temporary transcutaneous pacing (92953);
- Ventilation management (94002-94004, 94660, 94662); and
- Vascular access procedures (36000, 36410, 36415, 36591, 36600).5
Other separately billable services or procedures cannot be added to critical-care time. A notation in the medical record is highly recommended (e.g. “central-line insertion is not included as critical-care time”) for validation to prevent payor inquiries.
Do not count time associated with indirect care provided outside of the patient’s unit/floor (e.g. reviewing data or calling the family from the office) toward critical-care time. Activities on the floor/unit that do not directly contribute to patient care or management (e.g. review of literature, teaching rounds) cannot be counted toward critical-care time.
—Carol Pohlig
