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Inpatient Facility Coding & Compliance Alert

You Be the Coder:

Check This Before Billing Services for 2 Docs for Same Patient on Same Day

Published on Wed May 21, 2014

Question: I have a debate with our biller regarding   how to bill critical care codes when multiple providers are involved. At our larger hospital, we code and bill for the ED physician, the hospitalist and the physicians in critical care unit. My scenario is the following:  The patient arrives in the ED and requires 30 minutes of critical care services and then the care is transferred to a hospitalist that provides 40 minutes of critical care services. How would each separate group code for those services? I say they both code 99291 because they are separate groups. The biller feels the ED physician should report 99291 and the hospitalist should report their services utilizing 99292. Please help.

Washington Subscriber

Answer: The answer to your question is: it depends on the situation. 
 
Scenario 1: Two providers of the same specialty, in the same group, providing the same E/M service on the same day, for the same patient are deemed to be the same provider so the first hour of critical care would be reported with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and subsequent units of 99292 (… each additional 30 minutes) would be reported by the second provider as appropriate.
 
Scenario 2: If two physicians are of different specialties and different groups (often defined as different departments or different tax ID #s) have the same scenario, both would report 99291 for the first hour of critical care they provide. 
 
Take the following guidance from the CMS Transmittal 1548 (dated July 9 2008, Pub 100-04 Medicare Claims Processing):
 
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. CPT® code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care.
 
Clinical Example of Correct Billing of Time: A patient arrives in the emergency department in cardiac arrest. The emergency department physician provides 40 minutes of critical care services. A cardiologist is called to the ED and assumes responsibility for the patient, providing 35 minutes of critical care services. The patient stabilizes and is transferred to the CCU. In this instance, the ED physician provided 40 minutes of critical care services and reports only the critical care code ( CPT® code 99291) without additional ED E/M levels. The cardiologist may report the 35 minutes of critical care services (also CPT® code 99291) provided in the ED. Additional critical care services by the cardiologist in the CCU may be reported on the same calendar date using 99292 or another appropriate E/M code depending on the clock time involved. 
 
There are many other variations on this same general theme. It is possible to have situation in which there is an ED level along with critical care, for example, patient presents, receive typical ED care and then suddenly needs critical care services.

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