# Critical Care Coding question



## jojogi (Sep 18, 2017)

Teaching hospital environment.  Patient is critically ill and is seen by Dr. 1 for 40 minutes bills 99291.  Then, on the same day, there is a shift change and the pt is seen by Dr. 2 for an additional 35 min for same CC condition that flared up again.  Can Dr. 2 bill 99291 since its on the same day?


----------



## Tami_F (Sep 20, 2017)

*It depends*

This article from 2015 looks like a good resource. 



jojogi said:


> Teaching hospital environment.  Patient is critically ill and is seen by Dr. 1 for 40 minutes bills 99291.  Then, on the same day, there is a shift change and the pt is seen by Dr. 2 for an additional 35 min for same CC condition that flared up again.  Can Dr. 2 bill 99291 since its on the same day?



If Dr 1 and Dr 2 are from different specialties: yes. 
If Dr 1 and Dr 2 are from the same specialty: no. 
You mentioned that this is a teaching environment - only the time the attending/supervising physician spends providing critical care to the patient is billable. 

Per CPT: 
"Code 99291 is used to report the first 30-74 minutes of critical care on a given date. It should be used *only once per date* even if the time spent by the individual is not continuous on that date." (emphasis mine;  CPT 2017, pg 25)

Per CMS: 
"Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292. *Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician* (§30.6.5)." (emphasis mine; Medicare Claims Processing Manual, Chapter 12, pg 67)

"The CPT code 99291 is used to report the first 30 - 74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient *by the same physician or physician group of the same specialty*."  (emphasis mine; Medicare Claims Processing Manual, Chapter 12, pg 69)


What that means is that if Drs 1 and 2 both provide critical care to the patient on the same date of service and are part of the same specialty, the total amount of time they spent is billed. For the example you provided this is 75 minutes, so you would bill 99291 and 99292 under Dr 1, and nothing for Dr 2. 


Medicare Claims Processing Manual - Chapter 12


----------



## murphym (Apr 27, 2018)

*Critical Care scenario for Multiple providers within same specialty same DOS*

How would the following scenario be coded:

Dr. A spent 30 Critical Care minutes at 2:30 pm 

Dr. B spent 34 Critical Care minutes at 4:45 pm 

Dr. C spent 45 Critical Care minutes at 7:37 pm 

How would the following scenario be coded:

Dr. A spent 30 Critical Care minutes at 2:30 pm 

NP. B spent 34 Critical Care minutes at 4:45 pm 

Dr. C spent 45 Critical Care minutes at 7:37 pm

Providers must be billed separately to accurately capture the work they performed.

Thank you, I appreciate your help.

Madeline Murphy


----------



## msnbabs001 (May 3, 2018)

I am interested in the answers for the 2nd scenario too.  This seems to be a hot topic and very conflicting direction depending where you look.

I would offer another scenario.

How would the following scenario be coded:

 NP. A spent 30 Critical Care minutes at 2:30 pm 

 Dr. B spent 34 Critical Care minutes at 4:45 pm 


Thank you in advance for everyone's input.

Barb


----------



## coloradopa (Jun 29, 2018)

murphym said:


> How would the following scenario be coded:
> 
> Dr. A spent 30 Critical Care minutes at 2:30 pm
> 
> ...


First the reason there is an issue. APPs (PA and NP) are reimbursed at a different rate. This leaves the question about how to combine time. Another issue is the specialty code that is used. Since there is only one code for NPs (50) and PAs (97) this will  be different from the physicians and not obvious that they are the same specialty. This has lead to different rules depending on the MAC.
Here is Noridian guidance:
https://community.corporatecomplian...tFileKey=a56315f9-9706-4402-b47a-a00e81334e07
Page 45 details APP and MD documentation
Dr. Brown, a cardiologist
– Performs 40 minutes of critical care
• NPP same group
– Performs 35 minutes of critical care
• Billing
– 99291 under the MD’s NPI
– 99291 under the NPP’s NPI
• Note: Staff coverage or follow up after the
first hour a NPP may bill the 99292 

So according to this the NP B would bill a 99291 
Dr A would bill a 99291 and Dr C would bill a 99292

Or if it was all considered follow on care and they are treated as one physician:
Dr A Would bill a 99291
NP Bs time would be added to the 99291
Dr Cs time would be added to the 99291 and then bill 2 x 99292 (31 minutes)

Now in our shop we would bill according to our MAC instructions used to be Cahaba now Palmetto
Add the total time by like providers (MD and APP) then divide the time based on 99291-92. When different providers have time in the same slot the provider with most minutes gets the bill. 
In this case Drs A and C billed 75 minutes so bill a 99291
NP B has 34 minutes which would be 29 minutes (add one minute from Dr C) for a 99292 and an additional 99292 for the remaining 5 minutes. 

Finally if that's not confusing enough there are a number of coders that go off the CPT which states only one provider can bill the 99291. So if the initial provider meets the measure all the additional time is 99292. I this case it would look like this:
Dr A 99291
NP B 99292
Dr C 99292 x 2 (45 minutes + 4 minutes from NP B)


----------

