Gastroenterology Coding Alert

Question: Our gastroenterologist will occasionally be called to consult in the ICU to evaluate things like medication recommendations for a patient who appears to have a stomach infection while in an induced coma. The GI consistently submits critical care claims for these services, even though he’s only there briefly and doesn’t appear to be addressing the critical illness. We are trying to explain that he can’t bill critical care just because he’s on the ICU floor. Can you advise?

Codify Subscriber

Answer: You are correct that he shouldn’t be billing critical care solely because he’s on the ICU floor, and it’s a good idea to let him know that auditors are watching these claims. In fact, in early August 2018, CMS added a new topic to its Work Plan, entitled “Physicians Billing for Critical Care Evaluation and Management Services.” The new Work Plan item notes the following about critical care services and what the audit focus will be (emphasis is added by Gastroenterology Coding Alert):

“Critical care is defined as the direct delivery of medical care by a physician(s) for a critically ill or critically injured patient. Critical care is usually given in a critical care area such as a coronary, respiratory, or intensive care unit, or the emergency department. Payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care. Critical care is exclusively a time-based code. Medicare pays physicians based on the number of minutes they spend with critical care patients. The physician must spend this time evaluating, providing care and managing the patient’s care and must be immediately available to the patient. This review will determine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.”

Check out the following breakdown of the bolded provisions:

1. Critically Ill or Injured Patient: Whether the patient was critically ill or injured is perhaps the most important question you’ll need to answer on any critical care claim. You must be able to establish that the patient is critically ill or injured to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (...  each additional 30 minutes [List separately in addition to code for primary service]). CPT^®’s definition states, “A critical illness or injury acutely impairs one or more vital organ systems such that there is high probability of imminent or life-threatening deterioration in the patient’s condition.”

2. Payment May Be Made for Critical Care Services Provided in Any Location: The place of service for critical care when reporting 99291-+99292 is not restricted in CPT^® or based on CMS rules, other than to identify typical areas of a facility where it may occur. While most critical care will occur in a critical care area (ICU, ED, etc.), the physician can bill 99291 for services performed in any place of service the patient requiring it presents. The one site that is not allowable for critical care is an ambulance, unless the physician is treating a pediatric patient.

3. Exclusively A Time-Based Code: The duration of critical care services for both CPT^® and Medicare is based on the physician’s documentation of total time spent evaluating, managing, and providing care to the critical patient, as well as time spent in documenting such activities. The physician must devote full attention to the particular patient for every minute of time claimed.

The critical care codes 99291 and +99292 are used to report the total duration of time spent by a physician providing critical care services, even if the time spent by the physician on that date is not continuous. You can aggregate non-continuous time for critical care services for a single date. Use CPT^® code 99291 to report the first 30-74 minutes of critical care on a given date, but only report it once per date. Use code +99292 to report additional block(s) of time of up to 30 minutes each beyond the first 74 minutes of critical care.

4. Spend Time Evaluating, Providing Care, and Managing the Patient’s Care: The physician can spend the time at the patient’s bedside, reviewing test results, discussing the case with staff, documenting the medical record, and discussing the patient’s condition with family members (or surrogate decision makers) discussing specific treatment issues when the patient is unable or clinically incompetent to participate in providing history or making management decisions.

5. Immediately Available to the Patient: If you’re counting time toward critical care, you must be immediately available to the patient. If the physician leaves the building, goes to lunch, or ends his shift and leaves, you cannot count that time toward the critical care tally.

In the circumstance described, a hospital initial care or subsequent care code (99221-99223 or 99231-99233) would be more applicable than a critical care code.