# critical care involving MD and NP



## TTcpc

Hello, 

I am trying to clarify something for the group that I work with regarding physicians and NPs providing critical care services.  I know that critical care is not a split/shared service and that their time cannot be combined to meet the inital 99291.  My question is, if I have an NP who does 60 minutes of critical care time and then an MD in the same group comes in and provides an additional 25 minutes of time, then can we bill 99291 and 99292?  I am aware that the timeframe for 99291 is 30-74 minutes; however CMS states in the claims manual 30.6.13 Section H :   "However, if a physician or qualified NPP within a group provides ?staff coverage? or ?follow-up? for each other *after the first hour *of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the ?covering? physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292. 
So my question is:   is the first provider only responsible for the first 60 minutes and at 61 minutes the second provider can bill for 99292 as long as they exceed the 15 minute threshold???? 
This is a very heated topic that I have walked into with this job and I want to make sure that we get it cleared up.  The medical director has an article that he interpretes as requiring only reaching the 31 minute by the first one and past that the second can start their time.  I am trying to set up our policies according to CMS and our local carrier/Novitas, but as we all know sometimes they are as clear as mud then they want to punish you if you don't follow them the way that they do. 

Thank you!!


----------



## bugu32

*Deedee,Cpc coding manager*

Hi,
I have done a tremendous amount of research on critical care coding and if your physican and NP are billing based on both of their notes if it is one tax ID it is one group so you would need to treat it as one billing. The 99291= 30-74 mins of care so you have 60+25=85 mins the critical table reads 74-104=99291 + 99292. 
Total Duration of Critical Care Codes
Less than 30 minutes 99232 or 99233 or other appropriate E/M
code
30 - 74 minutes 99291 x 1
75 - 104 minutes 99291 x 1 and 99292 x 1
105 - 134 minutes 99291 x1 and 99292 x 2
135 - 164 minutes 99291 x 1 and 99292 x 3
165 - 194 minutes 99291 x 1 and 99292 x 4
194 minutes or longer 99291 ? 99292 as appropriate (per the above illustrations)
H. Critical Care Services and Other Evaluation and Management Services Provided 
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1548CP.pdf


----------



## slgarland

I am currently dealing with the issue of mid levels and Critical Care in my office. Besides the  CMS website, what websites do you use for guidance on this subject? Thank you!


----------



## coloradopa

twtcpc said:


> Hello,
> 
> I am trying to clarify something for the group that I work with regarding physicians and NPs providing critical care services.  I know that critical care is not a split/shared service and that their time cannot be combined to meet the inital 99291.  My question is, if I have an NP who does 60 minutes of critical care time and then an MD in the same group comes in and provides an additional 25 minutes of time, then can we bill 99291 and 99292?  I am aware that the timeframe for 99291 is 30-74 minutes; however CMS states in the claims manual 30.6.13 Section H :   "However, if a physician or qualified NPP within a group provides ?staff coverage? or ?follow-up? for each other *after the first hour *of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the ?covering? physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292.
> So my question is:   is the first provider only responsible for the first 60 minutes and at 61 minutes the second provider can bill for 99292 as long as they exceed the 15 minute threshold????
> This is a very heated topic that I have walked into with this job and I want to make sure that we get it cleared up.  The medical director has an article that he interpretes as requiring only reaching the 31 minute by the first one and past that the second can start their time.  I am trying to set up our policies according to CMS and our local carrier/Novitas, but as we all know sometimes they are as clear as mud then they want to punish you if you don't follow them the way that they do.
> 
> Thank you!!


As noted above, assuming the NP and MD are employed by the same entity you would bill the MD as follow on staff care. You would bill a 99291 under the NPs NPI for the first hour. Then you would bill a 99292 under the MDs NPI for the additional 30 minutes. There is a lot of confusion by Medicare carriers on this since the two providers are paid at different rates. A few carriers are not allowing an APP (PA or NP) and a physician to bill on the same patient. However, our carrier Cahaba is allowing the billing. For more information please see:
http://www.sccm.org/Communications/...Billing-Basics-Billing-for-Critical-Care.aspx
also specifically on APP billing make sure you read the additional notes:
http://www.sccm.org/SiteCollectionDocuments/Carpenter Sidebar.pdf


----------

