ED Coding and Reimbursement Alert

Count on coders to use correct payment rules.

The 2023 Medicare Physician Fee Schedule (MPFS) final rule is still yielding information that will be of interest to ED coders — and everyone who codes critical care.

The lowdown: The Centers for Medicare & Medicaid Services (CMS) tucked a technical correction into this year’s final rule, clearing up a lack of clarity and consistency regarding CMS policy on when you can report critical care add-on code +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).

The only problem is that the correction firmly puts Medicare payers and CPT^® at opposite ends of the spectrum when it comes to coding +99292. Read on for more information on this potentially confusing issue.

CMS: No +99292 Until 104 Minutes

In the 2023 final rule, CMS issued “Technical Correction for Split (or Shared) Critical Care Services.”

The correction states:
“In the CY 2022 PFS final rule … we finalized a number of billing policies for critical care CPT codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (each additional 30 minutes). … We stated in error, ‘Similar to our proposal for split (or shared) prolonged visits, the billing practitioner would first report CPT code 99291 and, if 75 or more cumulative total minutes were spent providing critical care, the billing practitioner could report one or more units of CPT code 99292.’”

This put CMS and CPT^® guidelines firmly on the same page, as both governing bodies called for a unit of +99292 to be reported after a critical care session reached the 75-minute threshold.

Then, the MPFS 2023 final rule came out, in which CMS reversed course. Per the final rule:

“We intended to state that CPT code 99292 could be billed after 104, not 75, or more cumulative total minutes were spent providing critical care. … our policy is that CPT code 99291 is reportable for the first 30-74 minutes of critical care services furnished to a patient on a given date. CPT code 99292 is reportable for additional, complete 30-minute time increments furnished to the same patient (74 + 30 = 104 minutes).”

Critical Care Claims Now More Payer-Specific

This makes coding for critical care more confusing, and will put the onus on coders when deciding whether to report +99292, says Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Michigan.

From now on, coders will need to ask “Where does time start?” for each +99292-eligible critical care encounter. “If you look at the CPT^® codes, it’s 99291 for the first 30 to 74 minutes. At 75 minutes, you would report +99292 — but not for CMS,” Young says. When you’re reporting by the Medicare rules, you need 104 minutes fulfill the full 30 minutes of the add-on code to report it.

So if you are considering +99292 there are miscoding risks that will come with the claim. Young recommends giving coders more power in order to streamline the critical care coding process and stay complaint.

“Physicians need to give the [critical care] times to their billers and let the billers apply the rules,” Young explains.

It has the potential to be a big issue, especially on longer critical care claims. As Young states, “105 minutes to one payer is +99292 and +99292 x 2 to another payer. This has the potential to be an entire +99292 payment.”

Win: You Can Code Critical Care With ED E/Ms

Although the MPFS final rule put CMS and CPT^® at the opposite end of the +99292 argument, it also clarified a ruling that benefits EDs when coding for Medicare patients.

According to the MFPS final rule: “We noted that the 2023 CPT Codebook provides instructions that critical care and ED services may be billed on the same day under certain circumstances. We referred readers to the CY 2022 PFS final rule, where we finalized our policy that critical care and ED visits may be billed on the same day if performed by the same physician, or by physicians in the same group and specialty if there is documentation that the E/M service was provided prior to the critical care service at a time when the patient did not require critical care, that the service is medically necessary, and that the service is separate and distinct, with no duplicative elements from the critical care service provided later in the day, and that practitioners may bill for both services.”

This makes sense, Young says, as the ED physician is still responsible for the patient before critical care occurs. “If they’re down there waiting for a room the ED is still responsible for them,” she explains. Now you have explicit permission from Medicare to report 99291/+99292 along with a code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/ or examination and high level of medical decision making) code set. This concept is already explicitly endorsed by CPT. Per CPT 2023, “Critical care and other E/M services may be provided to the same patient on the same date by the same individual.”