ED Coding and Reimbursement Alert

Critical Care:

Bust 5 Critical Care Myths for Clean Claims

Published on Mon Dec 13, 2021

Remember to keep an eye on the clock when performing critical care.

Although critical care cases are fairly common in the ED, that doesn’t mean the coding is straightforward. In fact, coding for these visits can be incredibly confusing. Take stock of these common 99291-+99292 pitfalls to make sure you’re not falling prey to critical care mythology.

Myth 1: Since Critical Care Is the Highest Level of E/M, You Must Satisfy All the E/M Elements

Reality: Actually, 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (-… each additional 30 minutes (list separately in addition to code for primary service)) are time-based codes — and if you look carefully at the code descriptor requirements in CPT^®, you’ll find no specific requirements for history, physical exam, or medical decision-making (MDM) that must be met before you report them.

ED coders may be accustomed to seeing codes in the ED E/M section of CPT^® that have specific key element requirements with regard to history, physical exam, and medical decision making.

For example, to report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history, a comprehensive examination, and medical decision making of high complexity…), you need a comprehensive history, comprehensive physical exam, and high-level MDM — but those requirements aren’t required for critical care. Instead, these are time-based codes that also require a high probability of imminent or life-threatening deterioration in the patient’s condition.

And that time must include at least 30 minutes of care, excluding any separately billable procedures the physician performs, such as endotracheal intubation.

Myth 2: Critical Care Must Take Place in the CCU or ICU

Reality: While physicians usually end up treating critical care patients in the designated critical care unit (CCU) or intensive care unit (ICU), critical care can actually take place anywhere. According to CPT^®, critical care isn’t specific to any location, such as an ICU or CCU. What determines whether you can report 99291 is the patient’s critical condition.

If necessary, the physician can perform critical care on the medical-surgical floor, in an observation unit, in a freestanding medical clinic, and certainly in the emergency department.

For example, the ED physician is working a clinical shift with dual coverage and responds to a code blue called by the radiology department. An inpatient was receiving an X-ray study, had a perforated ulcer, and went into cardiac arrest. The ED physician intubates the patient and restores her vital signs, starts her on dopamine and fluids, and gives her needed blood, all in the radiology suite.

The patient goes to surgery and ultimately returns to her bed in the inpatient unit. The physician documents 30 minutes of critical care. Even though the ED physician performed all the services in radiology, you would report this service with 99291. Keep in mind that the place of service for any services rendered to an inpatient would be 21 (Inpatient hospital).

Myth 3: The Physician’s Time Spent With Critical Care Patients Must Be Continuous

Reality: The time doesn’t have to be continuous, but the physician must devote the time documented as critical care exclusively to that patient. For example, the doctor attends to the patient at the bedside and makes an assessment. The physician can count the bedside time as critical care minutes (assuming the service meets all other critical care requirements) but must stop the clock when they leave. When the ED doctor later goes to radiology to look at an X-ray for that patient, the clock should be running again. If all this time adds up to 30 minutes or more, and the doctor documents the elements required for critical care, you should report the appropriate codes.

Myth 4: You Can Collect for 99291 and A Subsequent E/M Code for the Same Service Date

Reality: CPT^®doesn’t bar you from reporting a critical care service and another E/M service on the same day by the same physician — but some payers have edits in place that preclude you from getting reimbursed for both.

Payers may allow you to report an ED E/M code if you performed the E/M service prior to providing critical care to the patient. Of note, Medicare has changed its longstanding policy to allow this specific scenario starting in January, 2022. For instance, suppose a 65-year-old male undergoes a level-five evaluation for chest pain and is waiting for an inpatient bed. Two hours later, still in the ED, he suffers a Vfib arrest and the physician performs defibrillation and resuscitation, and starts the patient on a lidocaine drip. The doctor then administers 37 more minutes of care.

In this scenario, the E/M service happened first, so you would report 99285. After a drastic change in status, the patient required critical care, which you would report with 99291, assuming your payer doesn’t bar you from reporting the services together.

Medicare still does not allow reporting critical care followed by an ED E/M code. For example, a patient has an illness or injury that requires critical care services, then after stabilization, the patient still requires treatment in the ED. In this case, Medicare only allows reporting the critical care code.

Myth 5: If Two ED Physicians Simultaneously Provide Critical Care, They Can Both Bill for It

Reality: Medicare previously allowed only one provider to report critical care at a time. According to CMS Transmittal 2997, “Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient.”

Example: A 45-year-old female involved in a car crash presents with a femur fracture, pneumothorax, and ruptured spleen. Both the ED attending physician and the trauma attending provide critical care at the same time to this patient. In this case, only one of the doctors could report 99291.

This frequently led to confusion regarding whether the billing physician would be the ED doctor, and depended on intra-facility agreements more than the actualities of the care. In the above case, you might have one of two scenarios: The trauma attending might bill for critical care while the ED physician bills an ED E/M, or the trauma attending might bill a consult code while the ED physician bills critical care, assuming the patient’s insurer allows consultation codes.

Importantly, new for 2022, CMS has updated its policies regarding concurrent critical care as long as the providers are of different specialties.

“Thus, we proposed that critical care visits may be furnished as concurrent care (or concurrently) to the same patient on the same date by more than one practitioner in more than one specialty (for example, an internist and a surgeon, allergist and a cardiologist, neurosurgeon and NPP), regardless of group affiliation, if the service meets the definition of critical care and is not duplicative of other services,” CMS said in the 2022 Physician Final Rule.